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
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|General Information or Other |Event Number: 38319 |
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| 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 |
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| NRC NOTIFIED BY: STAN MARSHALL | |
| HQ OPS OFFICER: STEVE SANDIN | |
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|EMERGENCY CLASS: | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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| | |
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EVENT TEXT
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| 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." |
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|Hospital |Event Number: 38320 |
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| 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 |
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| NRC NOTIFIED BY: SCOTT DUBE | |
| HQ OPS OFFICER: STEVE SANDIN | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LADM 35.33(a) MED MISADMINISTRATION | |
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EVENT TEXT
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| 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. |
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Page Last Reviewed/Updated Thursday, March 25, 2021
Page Last Reviewed/Updated Thursday, March 25, 2021