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Event Notification Report for July 5, 2001

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           07/03/2001 - 07/05/2001

                              ** EVENT NUMBERS **

38114  

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|General Information or Other                     |Event Number:   38114       |
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| REP ORG:  COLORADO DEPT OF HEALTH              |NOTIFICATION DATE: 07/03/2001|
|LICENSEE:  KAISER PERMANENTE                    |NOTIFICATION TIME: 11:30[EDT]|
|    CITY:  DENVER                   REGION:  4  |EVENT DATE:        06/29/2001|
|  COUNTY:                            STATE:  CO |EVENT TIME:             [MDT]|
|LICENSE#:                        AGREEMENT:  Y  |LAST UPDATE DATE:  07/03/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |LINDA HOWELL         R4      |
|                                                |DONALD COOL          NMSS    |
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| NRC NOTIFIED BY:  TIM BONZER                   |                             |
|  HQ OPS OFFICER:  BOB STRANSKY                 |                             |
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|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
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                                   EVENT TEXT                                   
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| MEDICAL MISADMINISTRATIONS DUE TO INCORRECTLY CALCULATED RADIONUCLIDE        |
| ACTIVITIES                                                                   |
|                                                                              |
| The Syncor pharmacy in Denver, CO miscalculated the activity in three doses  |
| of I-131 due to the use of incorrect settings on the dose calibrator. Of the |
| three doses, two were delivered to a Kaiser Permanente facility and          |
| administered. The two doses were as follows:                                 |
|                                                                              |
| Dose 1 was ordered to be 5 mCi to be used for a whole body scan. Syncor      |
| believed that 5.28 mCi had been dispensed; however, the actual activity was  |
| 7.97 mCi.                                                                    |
|                                                                              |
| Dose 2 was ordered to be 15 mCi to be used for a hyperthyroid treatment.     |
| Syncor believed that 15.8 mCi had been dispensed; however, the actual        |
| activity was 24 mCi.                                                         |
|                                                                              |
| The state is currently following this issue with the Kaiser Permanente       |
| staff.                                                                       |
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