Event Notification Report for March 26, 2002
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
03/25/2002 - 03/26/2002
** EVENT NUMBERS **
38753 38797 38798 38799
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|General Information or Other |Event Number: 38753 |
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| REP ORG: ARKANSAS DEPARTMENT OF HEALTH |NOTIFICATION DATE:
03/07/2002|
|LICENSEE: ST BERNARDS REGIONAL HEALTH CTR |NOTIFICATION TIME: 14:57[EST]|
| CITY: JONESBORO REGION: 4 |EVENT DATE: 02/26/2002|
| COUNTY: STATE: AR |EVENT TIME: [CST]|
|LICENSE#: 365-BP-07-97 AGREEMENT: Y |LAST UPDATE DATE: 03/25/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |DAVE LOVELESS R4 |
| |JANET SCHLUETER NMSS |
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| NRC NOTIFIED BY: KIM WIEBECK | |
| HQ OPS OFFICER: GERRY WAIG | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| ST BERNARD'S REGIONAL MEDICAL CENTER MEDICAL MISADMINISTRATION |
| |
| The following event description is taken from a faxed report. |
| |
| "Description of Event: |
| |
| Following initial source send, the proximal gold marker could not be |
| discerned under fluoroscopy due to wire suture in the patients sternum. |
| Twenty-four seconds elapsed between the arrival of the distal marker at the |
| treatment site to source return to the delivery device. Two additional |
| source sends were attempted with immediate return of the sources due to the |
| inability to discern the proximal marker. Upon return of the sources to the |
| delivery device, all sources were visible in the source chamber but the |
| distal marker was not visualized. The treatment catheter was removed from |
| the patient while still attached to the delivery device. The catheter and |
| delivery device were placed into the bail-out box. The sources and distal |
| cold marker were successfully returned to the delivery device following |
| conclusion of the case." |
| |
| ***EVENT UPDATED 3/25/02 1135 EST BY FAX TO MIKE NORRIS*** |
| |
| The following was taken from a facsimile received from the Arkansas |
| Department of Health, Radiation Control and Emergency Management on |
| 3/25/02: |
| |
| "The Department received the licensee's written report via facsimile on |
| March 19, 2002, with the original mailed hardcopy received on March 21, |
| 2002. |
| |
| "The Department arranged for two qualified medical experts, a Radiation |
| Oncologist and an Interventional Cardiologist, both approved for the Novoste |
| Beta-Cath Devise, to review hardcopy cine images as well as a CD copy of the |
| cine film. Neither expert could visualize the proximal marker on the images. |
| In addition, one expert stated that they were unable to locate the source |
| beads on the images and therefore could not determine their location in the |
| body. In the final report, however, the licensee maintains that although the |
| proximal marker could not be visualized they believe that the entire source |
| train was delivered to the treatment site. |
| |
| "The licensee also submitted a dose calculation based on a 24-second dwell |
| time. This dwell time equated to a dose of 2.4 Gy delivered at a distance of |
| 2 mm from the centerline of the sources. The license's final report |
| indicated that the written directive had been revised to note a delivered |
| dose of 2.4 Gy to the target. The Department requested this revised written |
| directive, however, it was not provided. |
| |
| "Based on the information provided to the Department by the two qualified |
| experts, the Department does not agree with the licensee's determination |
| that the dose was delivered to the target area. Therefore, the Department is |
| classifying the event as a misadministration based on a 2.4 Gy dose |
| delivered to an unintended and undetermined area of the body. |
| |
| "The licensee's report indicated that the suggested cause of the device |
| failure was an inadequate connection of the treatment catheter or the fluid |
| management system. This conclusion was supported by the amount of fluid |
| accumulated in the sterile bag as well as the lack of pressure experienced |
| by the radiation oncologist during the case. In order to prevent further |
| occurrence, the licensee will perform an additional test run using the |
| active source. This test run will be conducted outside the patient on a |
| table located away from the cath lab staff. |
| |
| "In accordance with Department regulations, both the patient and the |
| referring physician were notified of the misadministration. A copy of the |
| licensee's final report was sent to the referring physician. |
| |
| "The Department considers this event closed." |
| |
| The NRC operations officer notified the R4DO (Chuck Cane) and NMSS EO (Janet |
| Schlueter). |
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|Other Nuclear Material |Event Number: 38797 |
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| REP ORG: SPECTRUM PHARMACIES INCORPORATED |NOTIFICATION DATE:
03/25/2002|
|LICENSEE: SPECTRUM PHARMACIES INCORPORATED |NOTIFICATION TIME:
10:48[EST]|
| CITY: REGION: 3 |EVENT DATE: 03/25/2002|
| COUNTY: ST JOE STATE: IN |EVENT TIME: 09:40[CST]|
|LICENSE#: 13-26367-01MD AGREEMENT: N |LAST UPDATE DATE: 03/25/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |PATRICK HILAND R3 |
| |JOHN HICKEY NMSS |
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| NRC NOTIFIED BY: SCOTT VANHEEFBERKE | |
| HQ OPS OFFICER: RICH LAURA | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|BAA1 20.1906(d)(1) SURFACE CONTAM LEVELS >| |
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EVENT TEXT
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| SHIPPING CONTAINER WITH REMOVABLE SURFACE CONTAMINATION EXCEEDING
THE |
| LIMITS |
| |
| The licensee received a shipping container (i.e., return ammunition can) |
| that had external contamination on the latch. An incoming survey found that |
| a contamination level of 227,345 DPM/300 centimeters squared of Tc-99m. The |
| can was opened and segregated and no internal contamination was found. The |
| driver and the steering wheel of the shipping vehicle was being surveyed. |
| The package originated from Memorial Hospital in South Bend, Indiana. The |
| licensee notified Memorial Hospital of the event. There were no known |
| personnel contamination at this time. |
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|Other Nuclear Material |Event Number: 38798 |
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| REP ORG: LANGAN ENGINEERING |NOTIFICATION DATE: 03/25/2002|
|LICENSEE: LANGAN ENGINEERING |NOTIFICATION TIME: 12:01[EST]|
| CITY: GREENWICH REGION: 1 |EVENT DATE: 03/25/2002|
| COUNTY: WARREN STATE: NJ |EVENT TIME: 07:00[EST]|
|LICENSE#: 29-15786-2 AGREEMENT: N |LAST UPDATE DATE: 03/25/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |RICHARD CONTE R1 |
| |JOHN HICKEY NMSS |
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| NRC NOTIFIED BY: MATHEW OLSEN | |
| HQ OPS OFFICER: MIKE NORRIS | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|BAB1 20.2201(a)(1)(i) LOST/STOLEN LNM>1000X | |
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EVENT TEXT
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| TROXLER MOISTURE DENSITY GAUGE STOLEN FROM A CONSTRUCTION TRAILER
|
| |
| A Troxler moisture density gauge containing 8 microcuries of Cs-137 and 40 |
| microcuries of Am-241/Be was stolen from a construction trailer located on |
| the corner State Highway 22 and Greenwich Street. The gauge was last seen |
| on 3/23/02 at 1330 EST when it was locked up in a construction trailer. It |
| was discover missing 3/25/02 at 0700. Greenwich NJ police department have |
| been notified. The gauge was a Troxler model 3440, serial number 29562. |
| The Licensee notified R1 (Lodhi). |
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|Power Reactor |Event Number: 38799 |
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| FACILITY: MAINE YANKEE REGION: 1 |NOTIFICATION DATE: 03/25/2002|
| UNIT: [1] [] [] STATE: ME |NOTIFICATION TIME: 16:08[EST]|
| RXTYPE: [1] CE |EVENT DATE: 10/29/2001|
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| NRC NOTIFIED BY: DON PENDAGAST |LAST UPDATE DATE: 03/25/2002|
| HQ OPS OFFICER: BOB STRANSKY +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |RICHARD CONTE R1 |
|10 CFR SECTION: | |
|APRE 50.72(b)(2)(xi) OFFSITE NOTIFICATION | |
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+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE
|
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N N 0 Decommissioned |0 Decommissioned |
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EVENT TEXT
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| OFFSITE NOTIFICATION REGARDING UNPLANNED EFFLUENT RELEASES |
| |
| The licensee notified the State of Maine regarding three separate |
| inadvertent liquid releases which occurred during the period from 10/29/2001 |
| through 11/12/2001. Each release involved approximately 1800 gallons of |
| water, with a combined total activity of 0.03 Ci. |
| |
| The licensee stated that the official notification had been delayed due to |
| disagreements regarding the wording of the notification with the state. NRC |
| Region I has been informed of this notification. |
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Page Last Reviewed/Updated Wednesday, March 24, 2021
Page Last Reviewed/Updated Wednesday, March 24, 2021