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Event Notification Report for May 23, 2003








                    U.S. Nuclear Regulatory Commission

                              Operations Center



                              Event Reports For

                           05/22/2003 - 05/23/2003



                              ** EVENT NUMBERS **



39868  39876  



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|General Information or Other                     |Event Number:   39868       |

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| REP ORG:  OK DEQ RAD MANAGEMENT                |NOTIFICATION DATE: 05/20/2003|

|LICENSEE:  OKLAHOMA UNIVERSITY MEDICAL CENTER   |NOTIFICATION TIME: 19:13[EDT]|

|    CITY:  OKLAHOMA CITY            REGION:  4  |EVENT DATE:        05/05/2003|

|  COUNTY:                            STATE:  OK |EVENT TIME:             [CDT]|

|LICENSE#:  OK-21035-01           AGREEMENT:  Y  |LAST UPDATE DATE:  05/20/2003|

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

|                                                |PERSON          ORGANIZATION |

|                                                |TROY PRUETT          R4      |

|                                                |JOHN HICKEY          NMSS    |

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

| NRC NOTIFIED BY:  PAM BISHOP                   |                             |

|  HQ OPS OFFICER:  MIKE RIPLEY                  |                             |

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

|EMERGENCY CLASS:          NON EMERGENCY         |                             |

|10 CFR SECTION:                                 |                             |

|NAGR                     AGREEMENT STATE        |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

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                                   EVENT TEXT                                   

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| AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION                           |

|                                                                              |

| The licensee reported a medical misadministration involving High Dose Rate   |

| brachytherapy MammoSite treatment to a 70-year old female.  Upon             |

| administering the first of ten planned fractions it was noticed that the     |

| Ir-192 source did not reach the center of the balloon but was near the       |

| periphery 30 millimeters from the center.  The patient dose was reassessed   |

| and it was determined that the dose to the target area was less than planned |

| (56% of the planned dose).  The patient and the patient's physician were     |

| notified.  It has been determined that there were no adverse effects to the  |

| patient.  Corrective actions will address four factors contributing to the   |

| misadministration: wrong orientation of the patient during a CT scan; delays |

| in issuing the treatment plan due to a computer network failure;             |

| mis-communications regarding the specified treatment plan; and similarities  |

| between CT-based and radiographic-based printouts.                           |

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|Power Reactor                                    |Event Number:   39876       |

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| FACILITY: OYSTER CREEK             REGION:  1  |NOTIFICATION DATE: 05/22/2003|

|    UNIT:  [1] [] []                 STATE:  NJ |NOTIFICATION TIME: 12:32[EDT]|

|   RXTYPE: [1] GE-2                             |EVENT DATE:        05/22/2003|

+------------------------------------------------+EVENT TIME:        12:00[EDT]|

| NRC NOTIFIED BY:  F. CIGNAIK                   |LAST UPDATE DATE:  05/22/2003|

|  HQ OPS OFFICER:  JOHN MacKINNON               +-----------------------------+

+------------------------------------------------+PERSON          ORGANIZATION |

|EMERGENCY CLASS:          NON EMERGENCY         |ANTHONY DIMITRIADIS  R1      |

|10 CFR SECTION:                                 |MICHELE EVANS        IRO     |

|APRE 50.72(b)(2)(xi)     OFFSITE NOTIFICATION   |                             |

|                                                |                             |

|                                                |                             |

|                                                |                             |

+-----+----------+-------+--------+-----------------+--------+-----------------+

|UNIT |SCRAM CODE|RX CRIT|INIT PWR|   INIT RX MODE  |CURR PWR|  CURR RX MODE   |

+-----+----------+-------+--------+-----------------+--------+-----------------+

|1     N          N       0        Refueling        |0        Refueling        |

|                                                   |                          |

|                                                   |                          |

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                                   EVENT TEXT                                   

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| WORK STOPPAGE BY IBEW LOCAL 1289 UNION.                                      |

|                                                                              |

| IBEW Local 1289 Union personnel implemented a work stoppage and started      |

| exiting the site at 1200 hours this date (05/22/03).  Required watch         |

| stations are being relieved by management personnel.                         |

|                                                                              |

| The NRC Resident Inspector was notified of this event by the licensee.       |

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