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Event Notification Report for May 13, 2004

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Event Reports For
05/12/2004 - 05/13/2004

** EVENT NUMBERS **


40732 40740

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General Information or Other Event Number: 40732
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: NEW ORLEANS CANCER INSTITUTE MEMORIAL MEDICAL CENTER
Region: 4
City: New Orleans State: LA
County:
License #: LA-10853-LO1
Agreement: Y
Docket:
NRC Notified By: SCOTT BLACKWELL
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/07/2004
Notification Time: 15:21 [ET]
Event Date: 05/07/2004
Event Time: [CDT]
Last Update Date: 05/07/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
TOM FARNHOLTZ (R4)
LAWRENCE KOKAJKO (NMSS)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was obtained from the Louisiana Department of Environmental Quality via facsimile:

"There was a Medical Event reported on April 7, 2004 concerning an incident that occurred on March 31-April 1, 2004. In the process of constructing a computer generated treatment plan for prostate Brachytherapy, a default switch that changes the source position calculation orientation from 'Connector End' to 'Catheter tip' was not adjusted to the correct orientation (Catheter/Needle tip). This led to the sources stopping short of the target and the total prescribed dose was not delivered. The facility was using a Nucletron Micro Selectron with a 7.315 [Curie] source of Ir-192. There was a total of three fractions for the treatment. One on March 31, 2004 and two on April 1, 2004. The total dose that was delivered was 1800 centigray to the wrong location. The misadministration is being compensated by external beam therapy. [There] are two causes for this event. The design of the default switch automatically selects an orientation that is not used at this facility and cannot be adjusted to default to the correct position. The other cause is operator error in not assuring that the orientation had been changed to read correctly. The patient is self-[referred] from Guatemala. The patient was informed immediately of the misadministration and received further external beam treatment. According to the Radiation Oncologist, no detrimental effects are expected. Actions taken to prevent further recurrence will be the addition of a visible check and documentation that the treatment plan was done with the source positions calculated from the tip end of the catheter or needle. This will be added to the pretreatment checklist which is performed and signed by the Radiation Oncologist, the Physicist, and the Dosimetrist. This checklist will be performed prior to initial treatment and at plan changes and is part of the patient's permanent record. There will also be a written notification to Nucletron regarding the potential danger of misadministration due to inability to change the default on the orientation 'switch'. The design should be that if the connector end is selected, the [planner] should be warned that this will change the source placement."

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General Information or Other Event Number: 40740
Rep Org: MARYLAND DEPT OF THE ENVIRONMENT
Licensee: CTI CONSULTANTS INC
Region: 1
City:  State: MD
County: MONTGOMERY
License #: MD-31-241-01
Agreement: Y
Docket:
NRC Notified By: BOB NELSON
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 05/10/2004
Notification Time: 11:10 [ET]
Event Date: 05/07/2004
Event Time: 13:30 [EDT]
Last Update Date: 05/10/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN ROGGE (R1)
TOM ESSIG (NMSS)

Event Text

TROXLER GAUGE RUN OVER BY BULLDOZER AT CONSTRUCTION SITE

A Troxler gauge model 3430 containing 10 millicuries Cs-137 and 40 millicuries AmBe-241 was run over by a bulldozer at a construction site in Montgomery County, MD. The device was completely destroyed, but the sources were not broken or leaking. The device was shipped to NE Technical Service in Westminster, MD and will be disposed of at a nuclear waste site in California..

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