United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated With Events > Event Notification Reports > 2001

Event Notification Report for September 27, 2001

                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           09/26/2001 - 09/27/2001

                              ** EVENT NUMBERS **

38319  38320  

+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   38319       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  NV DIV OF RAD HEALTH                 |NOTIFICATION DATE: 09/26/2001|
|LICENSEE:  SUMMIT ENGINEERING CORPORATION       |NOTIFICATION TIME: 17:45[EDT]|
|    CITY:  RENO                     REGION:  4  |EVENT DATE:        09/25/2001|
|  COUNTY:                            STATE:  NV |EVENT TIME:             [PDT]|
|LICENSE#:  00-11-0180-01         AGREEMENT:  Y  |LAST UPDATE DATE:  09/26/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |GREG PICK            R4      |
|                                                |PATRICIA HOLAHAN     NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  STAN MARSHALL                |                             |
|  HQ OPS OFFICER:  STEVE SANDIN                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:                                |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT INVOLVING POTENTIAL DAMAGE TO A PORTABLE GAUGE DURING |
| TRANSPORT                                                                    |
|                                                                              |
| "A portable gauge fell off the bed of the transporting pickup and was        |
| slightly damaged. The gauge was not carried in it's shipping container at    |
| the time of the incident. The guide rod (as opposed to the source rod) broke |
| near the base of the gauge. The source was in the safe, shielded position at |
| the time of the incident. The gauge has been surveyed and leak tested and    |
| has been shipped to an authorized repair facility. The gauge was a Humboldt  |
| 5001, s/n 400 containing 8 mCi of Cs-137 and 40 mCi of Am-241:Be.            |
|                                                                              |
| "Cause of the incident was lack of attention to detail. Event Report ID No.  |
| NV-01-005."                                                                  |
+------------------------------------------------------------------------------+

+------------------------------------------------------------------------------+
|Hospital                                         |Event Number:   38320       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG:  QUEENS MEDICAL CENTER                |NOTIFICATION DATE: 09/26/2001|
|LICENSEE:  QUEENS MEDICAL CENTER                |NOTIFICATION TIME: 22:07[EDT]|
|    CITY:  HONOLULU                 REGION:  4  |EVENT DATE:        09/26/2001|
|  COUNTY:  HONOLULU                  STATE:  HI |EVENT TIME:        09:00[HST]|
|LICENSE#:  53-16533-02           AGREEMENT:  N  |LAST UPDATE DATE:  09/26/2001|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |GREG PICK            R4      |
|                                                |PATRICIA HOLAHAN     NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  SCOTT DUBE                   |                             |
|  HQ OPS OFFICER:  STEVE SANDIN                 |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|LADM 35.33(a)            MED MISADMINISTRATION  |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| MEDICAL MISADMINISTRATION INVOLVING DELIVERY OF TREATMENT TO THE WRONG SITE  |
|                                                                              |
| At approximately 0900HST on 9/26, a patient undergoing treatment for         |
| restenosis of a cardiac vessel received a 23 gray dose using a Sr-90 source  |
| via intravascular brachytherapy.  The error occurred due to difficulty in    |
| resolving the correct vessel segment location using fluoroscopy imaging.     |
| The attending radiologist and cardiologist reviewed film concluding that the |
| wrong segment had been treated.  The prescribed dose was then delivered to   |
| the correct site.  The patient has not been informed and there are no        |
| adverse effects anticipated.  The licensee will meet with the vendor to      |
| discuss appropriate corrective actions in use of the equipment.              |
+------------------------------------------------------------------------------+