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Event Notification Report for March 11, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/10/2004 - 03/11/2004

** EVENT NUMBERS **


40540 40568 40569 40575 40580 40583

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Hospital Event Number: 40540
Rep Org: UNIVERSITY OF VIRGINIA HOSPITAL
Licensee: UNIVERSITY OF VIRGINIA HOSPITAL
Region: 1
City: CHARLOTTESVILLE State: VA
County:
License #:
Agreement: N
Docket:
NRC Notified By: RALPH ALLEN
HQ OPS Officer: RICH LAURA
Notification Date: 02/23/2004
Notification Time: 14:20 [ET]
Event Date: 02/21/2004
Event Time: 09:00 [EST]
Last Update Date: 03/10/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
20.2202(b)(1) - PERS OVEREXPOSURE/TEDE >= 5 REM
Person (Organization):
MOHAMED SHANBAKY (R1)
ROBERTO TORRES (NMSS)

Event Text

MISSING MEDICAL SOURCE FOR 2 HOURS AT UVA HOSPITAL

The licensee at University of Virginia Hospital reported an event where a radioactive medical source was missing for approximately 2 hours. The patient was being treated for uterine cancer. At the end of the treatment, the licensee removed 8 catheters from the patient. Unknown at the time, one ribbon with 8 seeds of Ir-192, with an approximate activity of 5 millicuries, fell onto the floor. The licensee performed a search and radiological surveys, and the missing ribbon was located 2 hours later in a trash compactor. The licensee is performing an assessment of any unplanned exposures that resulted from this event.

* * * UPDATE AT 1530 EST ON 2/24/04 FROM R. ALLEN TO E. THOMAS * * *

The licensee has concluded their assessment of any unplanned exposures from this incident, along with determining its root cause.

In the unlikely case that the patient was laying directly on top of the source (on contact) for the entire 30 minutes from the time the physicians removed the sources until the missing ribbon was discovered, her skin exposure would have been 662 rad. This exposure is less than her skin exposure from other treatments of the tumor thus far, and would result in minimal adverse effects. If the 30 minute exposure occurred at a distance of 1.5 millimeters from the patient, her exposure would have been 41 rad to the skin.

It is highly unlikely that the patient received anywhere near these exposure levels, as the missing ribbon was most likely picked up with other trash shortly after the room was de-posted, and prior to the physicians discovering the loss. In the brief time (1-2 minutes) it took to transport the ribbon with other trash to the dumpster, and during the time the ribbon was in the dumpster, any exposures to additional personnel would have been negligible.

The root cause of the lost ribbon is that the meter used to survey the room following the procedure was defective. Another meter was used to locate the ribbon in the trash compactor.

Notified R1DO (Shanbaky) and NMSS (Essig)

* * * UPDATE AT 1459 ON 3/10/04 FROM ALLEN TO GOTT * * *

Due to skin reddening on the patient, the patient may have received an over exposure to the thigh. It is unknown how long the source was stuck to the patient's skin or the exposure. The licensee is continuing to investigate.

Notified R1DO (Cobey) and NMSS (Brown)

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General Information or Other Event Number: 40568
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: CITY OF HOLDREGE, NE
Region: 4
City: HOLDREGE State: NE
County:
License #: GL-0428
Agreement: Y
Docket:
NRC Notified By: TRUDY HILL
HQ OPS Officer: MIKE RIPLEY
Notification Date: 03/05/2004
Notification Time: 12:39 [ET]
Event Date: 02/29/2004
Event Time: [CST]
Last Update Date: 03/05/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4)
FRED BROWN (NMSS)

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The City of Holdrege, NE reported that in late February 2004 during an annual inventory, it was discovered that 25 of 40 Tritium exit signs were missing. The signs were installed in stairways in the city auditorium. The signs are SafetyLite Model 2088 (2.2 Curies Tritium each as of the shipment date of March 1990). An investigation did not determine what happened to the signs and the State is closing the report.

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General Information or Other Event Number: 40569
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: MENARD'S LUMBER
Region: 4
City: OMAHA State: NE
County:
License #: GL-0401
Agreement: Y
Docket:
NRC Notified By: TRUDY HILL
HQ OPS Officer: MIKE RIPLEY
Notification Date: 03/05/2004
Notification Time: 12:39 [ET]
Event Date: 11/01/2003
Event Time: [CST]
Last Update Date: 03/05/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
GREG PICK (R4)
FRED BROWN (NMSS)

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

Menard's Lumber reported that following demolition and replacement of their old store building, it was determined that all 13 Tritium exit signs were missing and apparently removed along with the old building debris. The signs were SafetyLite/EvenLite Model 101 (7 Curies Tritium as of the manufacture date of October 1991). An investigation did not determine the final disposition of the signs and the State is closing the report.

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General Information or Other Event Number: 40575
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: CLEVELAND CLINIC FOUNDATION
Region: 3
City: CLEVELAND State: OH
County:
License #: 02110180013
Agreement: Y
Docket:
NRC Notified By: MARK LIGHT
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 03/08/2004
Notification Time: 10:15 [ET]
Event Date: 03/04/2004
Event Time: 16:00 [EST]
Last Update Date: 03/08/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KENNETH RIEMER (R3)
TOM ESSIG (NMSS)

Event Text

THE CLEVELAND CLINIC FOUNDATION ADMINISTERED AN UNDERDOSE DURING A THERAPEUTIC TREATMENT

During a therapeutic procedure using I-125 Gliasite from 2/28 - 3/1, the state licensee administered an under dose of 24%. The therapist calculated a dwell time of only 97 hours when the prescribed dwell time was 120 hrs for treating a brain tumor. This resulted in the patient receiving 5,300 rads instead of the prescribed 7,000 rads. Both the patient and the referring physician were notified. The licensee will make up for the under dosage by using a linear accelerator.

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Power Reactor Event Number: 40580
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: MIKE KELLER
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/10/2004
Notification Time: 15:00 [ET]
Event Date: 03/10/2004
Event Time: 08:35 [PST]
Last Update Date: 03/10/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
TROY PRUETT (R4)
TERRY REIS (NRR)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION DUE TO A FATALITY ONSITE

"This notification is being made to report an onsite fatality due to a personal medical condition. During the incident, plant First Responder personnel responded to a Control Room notification of a man down. First Responder personnel initiated CPR and used an Automated External Defibrillator (AED) and continued until the Hanford Fire Department ambulance paramedics responded. The individual was taken via ambulance to Kadlec Medical Center in Richland, Washington where the individual was pronounced dead at 0835 PST."

The fatality occurred in the Protected Area (PA) and was not associated with any work inside a Radiologically Controlled Area (RCA). The licensee informed the NRC Resident Inspector and will inform both state/local agencies.

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Transportation Event Event Number: 40583
Rep Org: CARDINAL HEALTH
Licensee: CARDINAL HEALTH
Region: 1
City: GLASTONBURY State: CT
County: HARTFORD
License #: 04-26507-01MD
Agreement: N
Docket:
NRC Notified By: WILLIE REGITS
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/10/2004
Notification Time: 20:22 [ET]
Event Date: 03/10/2004
Event Time: 07:00 [EST]
Last Update Date: 03/10/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
INFORMATION ONLY
Person (Organization):
EUGENE COBEY (R1)
TROY PRUETT (R4)
JOHN GREEVES (NMSS)

Event Text

TRANSPORT ACCIDENT INVOLVING RADIOACTIVE SPILL OF RADIOPHARMACEUTICAL

At approximately 0700 EST on 3/10/04, a courier vehicle dispatched from the Cardinal Health (formerly Syncor International) office in Glastonbury, CT overturned at Exit 43 eastbound on I-84 in West Hartford, CT. One of the pigs containing an unused Tc-99M syringe return was ejected from the vehicle. The syringe was crushed releasing an estimated 1-10 microcuries roadside. The local Fire Department responded closing the ramp for cleanup. The CT Department of Environmental Protection (DEP) was informed and arrived at the scene to take possession and isolate the syringe and pig. CT DEP notified the NRC Region I office (Duncan White, Tom Thompson) of the incident.

The licensee has prepared a press release to address any concerns. The local media is carrying the news story on their public website, i.e., www.WTNH.com. The licensee notified the National Response Center (DOT), case #715670.

Page Last Reviewed/Updated Friday, March 30, 2012
Friday, March 30, 2012