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Event Notification Report for April 3, 2003






                    U.S. Nuclear Regulatory Commission

                              Operations Center



                              Event Reports For

                           04/02/2003 - 04/03/2003



                              ** EVENT NUMBERS **



39710  39721  39722  





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|General Information or Other                     |Event Number:   39710       |

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| REP ORG:  TEXAS DEPARTMENT OF HEALTH           |NOTIFICATION DATE: 03/28/2003|

|LICENSEE:  BAKER ATLAS                          |NOTIFICATION TIME: 12:15[EST]|

|    CITY:  HOUSTON                  REGION:  4  |EVENT DATE:        03/26/2003|

|  COUNTY:                            STATE:  TX |EVENT TIME:        07:30[CST]|

|LICENSE#:  L05104                AGREEMENT:  Y  |LAST UPDATE DATE:  03/28/2003|

|  DOCKET:                                       |+----------------------------+

|                                                |PERSON          ORGANIZATION |

|                                                |BLAIR SPITZBERG      R4      |

|                                                |TRISH HOLAHAN        NMSS    |

+------------------------------------------------+                             |

| NRC NOTIFIED BY:  GLENN CORBIN                 |                             |

|  HQ OPS OFFICER:  HOWIE CROUCH                 |                             |

+------------------------------------------------+                             |

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| AGREEMENT STATE REPORT - INJURED AND CONTAMINATED EMPLOYEE TRANSFERRED       |

| OFFSITE                                                                      |

|                                                                              |

| The following information was obtained from Texas Department of Health,      |

| Bureau of Radiation Control via facsimile:                                   |

|                                                                              |

| "The Agency was notified that at 7:30 AM [CST] [on] 3/26/03, a neutron tube  |

| blew apart inside the pulse neutron facility located at 2001 Rankin Road,    |

| Houston, TX 77073-5114.  The employee that was involved received superficial |

| lacerations.  EMT's were notified at this time.  Immediately after the       |

| accident H-3 [tritium] contamination was found around the wound area.  The   |

| contamination was found in a swipe that was analyzed by the licensee using   |

| their laboratory located on the premises.  The swipe was found to have 19    |

| [nanocuries] of H-3 contamination.  The employee was transferred by          |

| ambulance to a local hospital.  We believe at this time it was Memorial      |

| Hospital.  The EMT's and the hospital were made aware of the radiological    |

| contamination and all precautions were taken.  The licensee requested that   |

| all materials removed or used at the hospital, and in the ambulance be       |

| returned to the licensee.  [Urinalysis] was [performed] on the employee and  |

| found to be at baseline levels.  Contamination was contained in the building |

| where the accident happened and contamination on the floor was               |

| decontaminated to background levels.  The licensee is following up with the  |

| hospital concerning the contaminated clothing, and debris associated with    |

| the incident.  The licensee will submit a report within thirty days."        |

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|Hospital                                         |Event Number:   39721       |

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| REP ORG:  MEDICAL CENTER OF BEAVER, PA         |NOTIFICATION DATE: 04/02/2003|

|LICENSEE:  MEDICAL CENTER OF BEAVER, PA         |NOTIFICATION TIME: 08:51[EST]|

|    CITY:  BEAVER                   REGION:  1  |EVENT DATE:        03/31/2003|

|  COUNTY:                            STATE:  PA |EVENT TIME:        14:00[EST]|

|LICENSE#:  37-11562-01           AGREEMENT:  N  |LAST UPDATE DATE:  04/02/2003|

|  DOCKET:                                       |+----------------------------+

|                                                |PERSON          ORGANIZATION |

|                                                |RONALD BELLAMY       R1      |

|                                                |TOM ESSIG            MNSS    |

+------------------------------------------------+                             |

| NRC NOTIFIED BY:  TONY COMBINE                 |                             |

|  HQ OPS OFFICER:  CHAUNCEY GOULD               |                             |

+------------------------------------------------+                             |

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|LOTH 35.3045(a)(3)       DOSE TO OTHER SITE > SP|                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| PATIENT RECEIVED A DOSAGE TO AN UNINTENDED TISSUE AREA                       |

|                                                                              |

| The patient had a HDR (High Dose Rate) treatment using 4-9 curies of Ir-192  |

| when the tube was inserted into the treatment area it was 6 cms short of     |

| going to the planned area to be treated.  This was caused by the wrong       |

| numbers being entered.  It is estimated that the patient received between    |

| 500 and 1,000 Rads to the wrong area.  The patient and prescribing physician |

| were informed.  There apparently was no adverse affects to the patient from  |

| this error.                                                                  |

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|Hospital                                         |Event Number:   39722       |

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| REP ORG:  UNIVERSITY OF MICHIGAN               |NOTIFICATION DATE: 04/02/2003|

|LICENSEE:  UNIVERISTY OF MICHIGAN               |NOTIFICATION TIME: 11:46[EST]|

|    CITY:  ANN ARBOR                REGION:  3  |EVENT DATE:        04/01/2003|

|  COUNTY:                            STATE:  MI |EVENT TIME:        16:00[EST]|

|LICENSE#:  21-00215-04           AGREEMENT:  N  |LAST UPDATE DATE:  04/02/2003|

|  DOCKET:                                       |+----------------------------+

|                                                |PERSON          ORGANIZATION |

|                                                |BRENT CLAYTON        R3      |

|                                                |THOMAS ESSIG         NMSS    |

+------------------------------------------------+                             |

| NRC NOTIFIED BY:  MARK DRISCOLL                |                             |

|  HQ OPS OFFICER:  ARLON COSTA                  |                             |

+------------------------------------------------+                             |

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|LDIF 35.3045(a)(1)       DOSE <> PRESCRIBED DOSA|                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| MEDICAL EVENT INVOLVING ADMINISTRATION OF LESS THAN PRESCRIBED DOSE          |

|                                                                              |

| A physician prescribed a dose for an outpatient therapy at 25 millicuries of |

| Iodine 131.  After completion of the treatment it was determined that the    |

| patient actually received an exposure of 18.1 or 27.6% less than the         |

| prescribed dose.   The empty vials of Iodine 131 were re-assayed and 6.4     |

| millicuries of Iodine 131 apparently remained adhered to the glass vial.     |

| The adherence of Iodine to the vial is being assessed by the Licensee and    |

| NRC Region 3.  The patient was notified of this incident by the attending    |

| physician and the patient will return for administration of the remaining    |

| dose.                                                                        |

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