Event Notification Report for May 13, 2011

SHIPPING CONTAINER CONTAMINATION LEVEL EXCEEDS THE SURFACE CONTAMINATION LIMITS

The following information was received by e-mail:

"Empty [Model] LR-230 shipping containers received from off-site where one (1) LR-230 had removable surface contamination above limits for alpha/beta activity on the outer surface of the container (~7,800 dpm/100 sq cm alpha and 13,300 dpm/100 sq cm beta). The LR-230 shipping containers are used to transport uranyl nitrate (<5.0 wt % U-235). Contamination was not related to container integrity. Contamination appears to be related to minor drips during unloading. Areas have been successfully decontaminated.

"There were no actual or potential safety consequences to workers, the public, or the environment."

The licensee notified the NRC Resident Inspector.

MEDICAL EVENT - WRONG RADIOPHARMACEUTICAL ADMINISTERED TO PATIENT

On 5/13/2011, a patient at the Lantheus Medical Imaging center was administered Indium 111 (Oxine - for labeling white blood cells) instead of Indium 111 (DTPA - for brain study), which was the prescribed radiopharmaceutical. Less than 1 milliCurie of Indium 111 (Oxine) was injected into the patient. The dose received by the patient was less than 5 Rem, and no injury was caused to the patient.

A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

* * * RETRACTION ON 5/17/11 AT 0939 FROM EDWARDO DIAZ TO MARK ABRAMOVITZ * * *

This event has been determined by the licensee not to be a medical event because the total dose is less than 0.05 Sv (5 Rem) required in 10CFR35.3045.

Notified the R1DO (Gray) and FSME (McIntosh).

AGREEMENT STATE REPORT - EARLY TERMINATION OF RADIATION THERAPY BECAUSE OF POWER SUPPLY VOLTAGE VARIATION

"On Wednesday May 18th, the licensee's radiation safety officer contacted the agency [Illinois Emergency Management Agency] to advise that a medical event had likely occurred the prior Friday. Based on their initial evaluation, 1 of the 10 fractions prescribed for a patient was not delivered as intended such that less than 50% of the expected dose was delivered during a fraction.

"The written directive indicates that the patient was scheduled to undergo 10 treatments to her breast twice a day over a period of 5 days. Each treatment involved 340 centiGy for a total written directive prescription of 3,400 centiGy. During the 6th fraction after completion of treatments in channels 1 and 2, the unit experienced a power supply error. Sensing the power variation, the device automatically withdrew the source and did not complete the treatment for channel 3. Although additional attempts were made to clear the error and continue the treatment, none of the remaining 4 channels could be finished. The licensee had experienced similar problems with the device the previous week which had resulted in a service call on May 10. At that time the power supply was adjusted to ensure operation within specifications. The unit operated normally following the repair until the event on the 13th. The power supply as well as main controller board was subsequently replaced by the manufacturer Saturday morning and the patient returned that afternoon to complete the remaining portion of the 6th fraction. All the remaining fractions were delivered without incident. The fraction which finished the overall treatment was completed Tuesday. There have been no errors or incidents noted since the replacement of the above components.

"The licensee is still investigating this incident with the manufacturer to conduct an engineering evaluation of the power supply failure, however the 'fail safe' design of the system operated as expected. The licensee's initial estimate was that the patient received 133 centiGy of the 340 centiGy intended fractional dose. The patient and the referring physician were advised of the event but since the remaining fractions of the treatment were completed under the revised treatment plan, no adverse affect on the patient is expected and no other additional action is anticipated."

The intended dose for this fraction was 3.4 Gy. The dose received was 1.3 Gy.

Illinois Report Number: 11058

A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

* * * RETRACTION FROM DAREN PERRERO TO VINCE KLCO ON 5/24/11 @ 0902 EDT * * *

The following information was received via email:

"On May 23, 2011 the licensee's medical physicist provided information to the agency [Illinois Emergency Management Agency] which demonstrated that the target volume involved in the interrupted fraction received a dose of 217 cGy of the prescribed 340 cGy rather than the conservatively estimated 130 cGy. This dose to the patient treatment volume represents 63% of the prescribed dose and therefore does NOT constitute a medical event as identified in regulations."

Notified R3DO (Cameron) and FSME EO (McIntosh)

VALVE FAILED LEAK TEST DUE TO A DISC/SHAFT ASSEMBLY MACHINING ISSUE

The following information was received by facsimile:

"After a valve failed a leak test, it was determined that a fixture to machine the valve disc was missing one of the locating pins that maintained the integrity of the shaft bore centerline when machining. It was determined that the pin was missing from the fixture from January 8, 2011, to April 7, 2011 .

"Fisher has conducted a review and determined that the only ASME Section III code and commercial grade dedicated parts machined during this time that would use this fixture were the parts used for the orders referenced [below].

"Fisher Controls has implemented a corrective action program to address this issue.

"Although this notice is dated July 5, 2011 , Palo Verde was officially notified May 13, 2011, when Fisher first became aware of this issue. In the mean time, all affected discs have been returned to Fisher Controls for evaluation.

"Subject: NPS 16 Type A11 Disc/Shaft Assemblies for Palo Verde Orders 500541604 and 500548617 (Fisher Orders 019-F514977 and 019-F515346)."