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Event Notification Report for May 19, 2004

U.S. Nuclear Regulatory Commission
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Event Reports For
05/18/2004 - 05/19/2004

** EVENT NUMBERS **


40742 40747 40757

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General Information or Other Event Number: 40742
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSITY HOSPITAL
Region: 3
City: CINCINNATI State: OH
County:
License #: 02110-31-0010
Agreement: Y
Docket:
NRC Notified By: MARK LIGHT
HQ OPS Officer: CHAUNCEY GOULD
Notification Date: 05/13/2004
Notification Time: 09:17 [ET]
Event Date: 05/10/2004
Event Time: [EDT]
Last Update Date: 05/13/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANNE MARIE STONE (R3)
ROBERTO TORRES (NMSS)

Event Text

MEDICAL MISADMINISTRATION

On May 10, 2004 two patients were scheduled for administration of diagnostic dosages of radioiodine. Patient A was scheduled to have administered 2 millicuries I-131 Na - l for a thyroid cancer ("CA") workup to determine the appropriate I-131 Na - l therapeutic dosage for treatment of thyroid cancer. Patient B was scheduled to have administered 200 microcuries of I-123 Na - l for a thyroid uptake and scan to determine the appropriate therapeutic dosage of I-131 Na - l for hyperthyroidism. Both patients were small, elderly, Caucasian women and both had been previously treated at TUH Nuclear Medicine.

Patient B (hard of hearing) was checked in as Patient A and responded affirmatively to being addressed as Patient A. The technologist believed he knew the patient, believed the correct patient responded so he administered the 2 millicuries of I-131 Na - I to Patient B.

The error was discovered when an Administrative Assistant in the department addressed the patient as Patient A and the patient responded she was Patient B.

The prescribing physician informed Patient B of the misadministration during her appointment on May 11, 2004. The prescribing physician informed the referring physician's office of the misadministration on May 11, 2004.

This incident occurred because the technologist did not follow departmental, hospital, Radiation Control and Safety Program and QMP policies regarding proper identification of patients. All policies require technologists use two separate methods for verifying the identification of the patient. The technologist thought he knew the patient; however, he was incorrect with this assumption. In addition, the technologist did not use an accepted second method of identifying the patient. The second method of identification used by the technologist was estimating the patient's apparent age with the date of birth listed.

No adverse effect is expected for the patient. Patient B was scheduled to receive a therapeutic dose of I-131 Na - I the day after the misadministration occurred. The prescribing physician indicated he would administer the calculated treatment dose minus the 2 millicuries administered from the misadministration. On May 11, 2004 the appropriate dosage for patient B's hyperthyroid treatment was determined to be 17 millicuries. Patient B was administered 15.56 millicuries (prescribed as 17 millicuries - 2 millicuries or 15 millicuries) on May 11, 2004.

Technologists shall be expected to strictly follow hospital, departmental, Radiation Control and Safety Program and QMP policies requiring patient identification using a minimum of two identification methods. Identification of patients by a member of hospital staff, such as the technologist performing the procedure, should be eliminated as an approved mechanism for one of the two identification methods.

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General Information or Other Event Number: 40747
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: SRB TECHNOLOGIES
Region: 1
City: WINSTON SALEM State: NC
County:
License #: 034-0534-1
Agreement: Y
Docket:
NRC Notified By: LEE COX
HQ OPS Officer: MIKE RIPLEY
Notification Date: 05/14/2004
Notification Time: 10:20 [ET]
Event Date: 05/11/2004
Event Time: [EDT]
Last Update Date: 05/14/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN ROGGE (R1)
LINDA GERSEY (NMSS)

Event Text

AGREEMENT STATE REPORT - TRITIUM EXIT SIGNS LOST IN SHIPMENT

The following information was received via facsimile (North Carolina Incident report 04-19):

"The shipment was picked up from SRB Technologies, Inc. in Winston Salem, NC. The shipment was to be delivered to Wild Sales Co. in Santa Fe Springs, CA by Pilot Air Freight (shipment #070743258). Pilot Air Freight picked up a shipment of 14 boxes of which 13 boxes contained 129 tritium exit signs from the licensee on April 23, 2004. The balance of 1 box contained sign accessories/hardware. The sign customer notified the licensee that a box was missing on April 28, 2004. Pilot freight was immediately informed and they began investigating. Final confirmation was given to the licensee on May 11, 2004 that the box could not be located. The missing box contained 10 exit signs each containing 9.9 curies of tritium. The serial numbers of the missing signs are 316493-316502."

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Power Reactor Event Number: 40757
Facility: OCONEE
Region: 2 State: SC
Unit: [ ] [2] [ ]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: DEAN PORTER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/18/2004
Notification Time: 16:04 [ET]
Event Date: 05/18/2004
Event Time: 13:55 [EDT]
Last Update Date: 05/18/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xii) - OFFSITE MEDICAL
Person (Organization):
JAY HENSON (R2)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Refueling 0 Refueling

Event Text

POTENTIALLY CONTAMINATED INJURED PERSONNEL TRANSPORTED TO OFFSITE MEDICAL FACILITY

The following information was obtained by the licensee via facsimile:

"At 1355 [hrs. EDT] on 5/18/04, a vendor employee working in Unit 2's Reactor Building felt ill and passed out. Individual was transported as potentially contaminated to Oconee Memorial Hospital. Offsite medical personnel were notified to treat [the] individual as contaminated. Oconee Nuclear Station Radiation Protection Technician accompanied individual to [the] hospital to complete contamination survey.

"At 1515 [hrs.], Oconee Nuclear Station Radiation Protection Technician reported from [the] hospital that the individual has been determined to not be contaminated and was not at the time he left Oconee Nuclear Station."

Transport of individual was via Oconee County Ambulance. Oconee Nuclear Station first responders treated the individual until offsite medical assistance arrived. The injured person was performing work in a contaminated area. The contractor is currently in stable condition at Oconee Memorial Hospital.

The licensee has notified the NRC Resident Inspector.

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