Event Notification Report for May 16, 2002
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/15/2002 - 05/16/2002
EVENT NUMBERS
38923
General Information or Other
Event Number: 38923
Rep Org: COLORADO DEPT OF HEALTH
Licensee: LUTHERAN MEDICAL CENTER
Region: 4
City: State: CO
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TIM G. BONZER (fax)
HQ OPS Officer: MIKE NORRIS
Licensee: LUTHERAN MEDICAL CENTER
Region: 4
City: State: CO
County:
License #:
Agreement: Y
Docket:
NRC Notified By: TIM G. BONZER (fax)
HQ OPS Officer: MIKE NORRIS
Notification Date: 05/16/2002
Notification Time: 18:29 [ET]
Event Date: 05/16/2002
Event Time: 00:00 [MDT]
Last Update Date: 05/16/2002
Notification Time: 18:29 [ET]
Event Date: 05/16/2002
Event Time: 00:00 [MDT]
Last Update Date: 05/16/2002
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
GREG PICK (R4)
C.W. (BILL) REAMER (NMSS)
GREG PICK (R4)
C.W. (BILL) REAMER (NMSS)
AGREEMENT STATE REPORT ON MEDICAL MISADMINISTRATION
"[ ]Med. Physicist called on the date of this memo. It was regarding the placing of 111 seeds [of I-125] when the prescribed dose was 110 seeds. Per the physicist he could not see the additional seed because of the blood. After doing a source count he believes the additional seed was implanted into the patient. The additional seeds activity was 0.33 mCi. Additional information will follow."
"[ ]Med. Physicist called on the date of this memo. It was regarding the placing of 111 seeds [of I-125] when the prescribed dose was 110 seeds. Per the physicist he could not see the additional seed because of the blood. After doing a source count he believes the additional seed was implanted into the patient. The additional seeds activity was 0.33 mCi. Additional information will follow."