Event Notification Report for January 17, 2013

AGREEMENT STATE REPORT - PROSTATE SEED IMPLANT UNDERDOSE

A prostate patient received a medical order for 74 I-125 seeds (144 Gray). The implantation was performed on January 17, 2013 with three seeds being recovered in the operating room and the patient passed two seeds. The post surgery CT scan was performed on February 20, 2013 and the post plan was performed on February 25, 2013. It was determined that the D90 dose was 60% of the prescribed dose. The physician and patient will be notified today, February 25, 2013.

The Iowa Department of Public health is planning an on-site inspection for February 27, 2013.

* * * UPDATE FROM DAHLIN TO KLCO ON 3/4/2013 AT 1257 EST * * *

The following information was received from the State of Iowa by email:

"...The post plan dosimetry was completed on February 25, 2013 where it was discovered that the D90 for the implant was 60%. The licensee immediately notified IDPH [Iowa Department of Public Health]. The patient and referring physician were also notified that same day. An IDPH inspector conducted an onsite investigation of the event on February 28, 2013. The inspector met with and interviewed the radiation oncologist, the medical physics staff and several hospital administrators. The inspector reviewed the patient chart including the written directive, the treatment pre-plan, the operating room notes and the treatment post plan. During the interviews and chart review it was determined that an additional nine I-125 seeds had migrated out of the prostate to an area slightly inferior to the prostate. The radiation oncologist and medical physics staff believe that the seed migration occurred along the needle path and was due to the bowel movement issues that the patient experienced post implant. Additionally, the treatment pre-plan was based on an ultrasound contoured prostate volume of 38.59 cc. The treatment post-plan was based on a CT scan contoured prostate of 21.61 cc. The urologist, radiation oncologist and medical physics staff determined that the D90 of 60% was due to the loss of the additional nine I-125 seeds that migrated out of the prostate and the shrinking of the prostate from 38.59 cc to 21.61 cc. The patient will receive an external beam boost to the prostate. In addition, the post-plan dosimetry showed that the rectum and bladder received a dose less than expected on the preplan. The radiation oncologist and urologist stated that the under dose to the prostate from the seed implant therapy will not have an adverse effect on the health of the patient. No corrective actions can be performed due to the licensee having no control over seeds that migrate out of the prostate."

Iowa Item Number: IA130001

Notified the R3DO (Valos) and FSME Resources via email.

FIRE IN SWITCHYARD CIRCUIT BREAKER

"Failure of Unit 2 McGuire switchyard Power Circuit Breaker (PCB) 55 resulted in a fire and damage to the PCB. PCB 55 and the McGuire switchyard are located outside of the protected area. The fire was confined to the PCB only and extinguished by offsite municipal fire department in 33 minutes. This breaker affects the offsite transmission supply to Rock Springs and South Mountain. The Unit 2 plant breakers connecting offsite to onsite power were not affected and remain in service. The failure of PCB 55 did not damage any plant equipment nor did this event cause a plant transient. An estimated 50 gallons of oil has spilled from the damaged equipment which is contained to the immediate area. The spilled oil cleanup efforts are underway at this time."

The NRC Resident Inspector will be informed.