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Event Notification Report for August 27, 2002


                    U.S. Nuclear Regulatory Commission
                              Operations Center

                              Event Reports For
                           08/26/2002 - 08/27/2002

                              ** EVENT NUMBERS **

39141  

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|General Information or Other                     |Event Number:   39141       |
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| REP ORG:  WA DIVISION OF RADIATION PROTECTION  |NOTIFICATION DATE: 08/21/2002|
|LICENSEE:  PROVIDENCE EVERETT MEDICAL CENTER    |NOTIFICATION TIME: 15:02[EDT]|
|    CITY:  EVERETT                  REGION:  4  |EVENT DATE:        08/19/2002|
|  COUNTY:                            STATE:  WA |EVENT TIME:             [PDT]|
|LICENSE#:  WN-M0135-1            AGREEMENT:  Y  |LAST UPDATE DATE:  08/21/2002|
|  DOCKET:                                       |+----------------------------+
|                                                |PERSON          ORGANIZATION |
|                                                |WILLIAM JOHNSON      R4      |
|                                                |DOUG BROADDUS        NMSS    |
+------------------------------------------------+                             |
| NRC NOTIFIED BY:  TERRY C. FRAZEE (e-mail)     |                             |
|  HQ OPS OFFICER:  MIKE NORRIS                  |                             |
+------------------------------------------------+                             |
|EMERGENCY CLASS:          NON EMERGENCY         |                             |
|10 CFR SECTION:                                 |                             |
|NAGR                     AGREEMENT STATE        |                             |
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                                   EVENT TEXT                                   
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| AGREEMENT STATE REPORT INVOLVING MEDICAL MISADMINISTRATION                   |
|                                                                              |
| "The licensee reported that a patient received 2640 cGy (rad) during a       |
| cardiac intravascular brachytherapy treatment instead of the intended 2000   |
| cGy (rad), a 32% overexposure.  The patient was being treated with the       |
| Guidant Corporation Galileo intravascular brachytherapy high dose rate       |
| remote afterloader device (serial #27958502) with a model GDT-P32-2 source   |
| wire (serial #020807016) containing 4.44 GBq (119.9 [millicuries]) of P-32   |
| at time of treatment.  The patient's vessel size was larger than the         |
| automatically calculated maximum diameter treatment.  A manual calculation   |
| of dwell time was required, based on the dose rate tables available in the   |
| Guidant Manual (section 6.13 table 5).  However, the dose rate for a 4.6 mm  |
| diameter (3.30 mm treatment depth) was inadvertently used instead of 4.05 mm |
| diameter (3.03 mm treatment depth). This resulted in a delivered dose of     |
| 2640 cGy (rad) at 3.03 mm.  The cause of the event is human error.  The      |
| licensee's corrective action is to have a second independent calculation     |
| performed by Physics and Dosimetry staff prior to treatment whenever a       |
| manual calculation using the dose rate tables is necessary.  No adverse      |
| consequences are expected. The referring physician and the patient were      |
| notified of the overexposure."                                               |
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