Event Notification Report for July 12, 2002

AGREEMENT STATE REPORT INVOLVING A MEDICAL MISADMINISTRATION

"The Technologist (S.H) received a request to perform a Bone Scan on an inpatient. She selected an MDP Dose (25.1 mCi) and proceeded to the room listed on requisition. She approached the patient stated the name. The patient acknowledged the name. The technologist explained the procedure and injected the patient. When the patient presented to the Nuclear Medicine Department with hospital chart it was discovered that the misadministration had occurred. The technologist notified the authorized user, the referring physician [and] the Radiation Safety officer. The referring physician agreed to notify the patient. The Technologist was reinstructed to check the hospital chart for a written order and verify the patients identity by checking the hospital ORM board."

Used Tc-99m MDP Bone.

*****RETRACTED ON 7/18/02 AT 15:27 EDT FROM VOLPE TO LAURA*****

The licensee determined the event was NOT reportable since the dose was below the threshold (greater than 5 REM whole body or greater than 50 REM for organs) for reportability.

Notified R2DO (C. PAYNE) and NMSS (F. Brown).

AGREEMENT STATE REPORT INVOLVING EQUIPMENT FAILURE OF SHIPPING CONTAINER

"Event Report ID No.: TN-02-094

"License No.: R-73008

"Licensee: Duratek Radwaste Processing, Inc.

"Event date and time: July 12, 2002, 0830EDT

"Event location: Oak Ridge, Tennessee

"Event type: Equipment failure

"Notifications: USNRC Region II

"Event description: Duratek Radwaste Processing, Inc., a Tennessee licensee, called the Knoxville Field Office Manager to report that a sealand container of metals from Calvert Cliffs Nuclear Power Plant was received at the Duratek facility on July 12, 2002. During performance of the receipt survey/inspection, metal from the interior was observed protruding approximately 1/2" from a penetration in the side of the container. No detectable contamination was found on the accessible item or on the adjacent sealed surfaces. The penetration in the container wall was covered to permit undisturbed storage pending further investigation.

"Media attention: None"

REACTOR TRIP ON UNDERVOLTAGE ON REACTOR COOLANT PUMP BUSSES

"At approximately 2223 on 07/12/2002, Sequoyah Unit 2 (SQN-2) received an Automatic Reactor Trip on Reactor Coolant Pump Busses undervoltage. The cause of the undervoltage was due to the loss of the Unit 2, 2B and 2D unit boards as a result of a loss of the 2B Start Bus. The 2B and 2D Unit Boards are the 6.9 kV electrical feeds to the 2-2 and 2-4 RCPS, respectively. Plant response as a result of the loss of the Unit Boards was as expected, including the emergency start of all emergency diesel generators and the 2A-A Shutdown board being fed from Its emergency diesel generator.

"Plant personnel were in the process of returning the 'B' Common Station Service Transformer (B-CSST) to service at the time of the event. The plant is currently being maintained in Mode 3 at NOT/NOP, 547 degrees F/ 2235 psig respectively, by use of the plant's auxiliary feedwater system and steam dump system.

"The cause of the trip of the 25 start bus is unknown at this time and investigation is on going. The Unit 2 Loop 4 atmospheric relief valve (2-PCV-1-30) which opened on the Reactor Trip and did not reclose. Manual operator action was taken to close the affected valve."

The licensee notified the NRC Resident Inspector.

AGREEMENT STATE REPORT REGARDING INCORRECT ENTRY OF CATHETER POSITION/LENGTH INTO THE TREATMENT PLANNING SYSTEM RESULTING IN MISMATCHED HDR DWELL TIME AND CATHETER AT SWEDISH MEDICAL CENTER IN SEATTLE, WASHINGTON

The following text is a portion of an e-mail received from the WA Department of Health, Division of Radiation Protection:

"This is notification of an event in Washington state as reported to the WA Department of Health, Division of Radiation Protection."

"STATUS: new"

"Licensee: Swedish Medical Center"

"City and state: Seattle, WA"

"License number: WN-m008-1"

"Type of license: medical broad scope"

"Date of event: July 11, 2002"

"Location of Event: Seattle, WA"

"ABSTRACT: (where, when, how, why; cause, contributing factors, corrective actions, consequences, DOH onsite investigation; media attention) Incorrect entry of catheter position/length into the treatment planning system resulted in mismatched HDR dwell time and catheter. The error was noted after the second of four planned treatments. Estimates of the actual doses already delivered indicated from 17% to 25% underexposure to certain target volumes and 25% to 50% additional exposure to adjacent normal tissue. Each of the four treatments was intended to deliver 600 centigray through three catheters with varying dwell times. In effect, two catheters were 'reversed' in the planning system and a 'long' dwell was used in a 'short' catheter, and vice versa. At the end of the second treatment, a significant volume of the target tissue received only 900 to 1000 centigray instead of the intended 1200 centigray. The licensee determined that the overall therapy was "salvable" and by modifying subsequent treatments would be able to correct the dose to the target tissue and at the same time minimize any additional dose to the adjacent normal tissue. No adverse effects are anticipated. The licensee generates a customized plan and treatment verification flow chart under its quality assurance program for each patient. The licensee has determined that the sign-off for 'number of catheters' needs to be modified to 'number and labeling of catheters' as the appropriate corrective action."

"What is the notification or reporting criteria involved? WAC 246-240-050
Notifications, records, and reports of therapy misadministrations."

"Activity and Isotope(s) involved: 3.3 Ci Ir-192"

"Device (HDR, etc.) Mfg., Model; computer program: Nucletron MicroSelectron-HDR 'Classic' "

"Exposure (intended/actual); consequences: 1200 centigray intended/900 centigray actual"

"Was patient or responsible relative notified? (will be)"

"Was written report provided? (not yet)"

"Was referring physician notified? YES"

"Consultant used? NO"

(Contact the NRC operations officer for State contact information.)