United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated With Events > Event Notification Reports > 2002

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  
.
+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   39054       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| 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    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  MILLER                       |                             |
|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| 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.                                          |
+------------------------------------------------------------------------------+
.
+------------------------------------------------------------------------------+
|General Information or Other                     |Event Number:   39055       |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| 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    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  TERRY C. FRAZEE              |                             |
|  HQ OPS OFFICER:  LEIGH TROCINE                |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
|                                                |                             |
+------------------------------------------------------------------------------+

                                   EVENT TEXT                                   
+------------------------------------------------------------------------------+
| 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.)          |
+------------------------------------------------------------------------------+
.