Event Notification Report for July 18, 2002
U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
07/17/2002 - 07/18/2002
** EVENT NUMBERS **
39054 39055
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|General Information or Other |Event Number: 39054 |
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| REP ORG: NE DIV OF RADIOACTIVE MATERIALS |NOTIFICATION DATE: 07/12/2002|
|LICENSEE: SYNCOR PHARMACY |NOTIFICATION TIME: 11:22[EDT]|
| CITY: OMAHA REGION: 4 |EVENT DATE: 07/05/2002|
| COUNTY: STATE: NE |EVENT TIME: 10:00[CDT]|
|LICENSE#: 01-65-01 AGREEMENT: Y |LAST UPDATE DATE: 07/12/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |THOMAS ANDREWS RDO |
| |FRED BROWN NMSS |
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| NRC NOTIFIED BY: MILLER | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| SYNCOR PHARMACY REPORTED THAT A DELIVERY VEHICLE CONTAINING
TECHNETIUM 99 |
| WAS STOLEN |
| |
| A courier vehicle carrying a Yellow II labeled package containing 125 |
| millicuries of Technetium 99m was stolen in Omaha, NE on 7/5/02. The driver |
| had stopped briefly to perform a personnel errand while he was on a delivery |
| to Norfolk, NE. As of this date, neither the vehicle nor the nuclear |
| pharmaceutical have been located. The local police have been notified and |
| there has been some media interest. |
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|General Information or Other |Event Number: 39055 |
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| REP ORG: WA DIVISION OF RADIATION PROTECTION |NOTIFICATION DATE:
07/12/2002|
|LICENSEE: SWEDISH MEDICAL CENTER |NOTIFICATION TIME: 17:12[EDT]|
| CITY: SEATTLE REGION: 4 |EVENT DATE: 07/12/2002|
| COUNTY: STATE: WA |EVENT TIME: [PDT]|
|LICENSE#: WN-m008-1 AGREEMENT: Y |LAST UPDATE DATE: 07/12/2002|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |GAIL GOOD R4 |
| |M. WAYNE HODGES NMSS |
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| NRC NOTIFIED BY: TERRY C. FRAZEE | |
| HQ OPS OFFICER: LEIGH TROCINE | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| 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.) |
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