United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2004 > December 9

Event Notification Report for December 9, 2004

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/08/2004 - 12/09/2004

** EVENT NUMBERS **


41210 41249

To top of page
General Information or Other Event Number: 41210
Rep Org: MISSISSIPPI DIV OF RAD HEALTH
Licensee: BAPTIST MEMORIAL HOSPITAL - NORTH MISSISSIPPI
Region: 1
City:  State: MS
County:
License #: MS-232-02
Agreement: Y
Docket:
NRC Notified By: BOBBY SMITH
HQ OPS Officer: STEVE SANDIN
Notification Date: 11/19/2004
Notification Time: 12:36 [ET]
Event Date: 11/18/2004
Event Time: [CST]
Last Update Date: 12/08/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KENNETH JENISON (R1)
SCOTT MOORE (NMSS)

Event Text

AGREEMENT STATE REPORT INVOLVING A THERAPY MISADMINISTRATION

The following information was provided via email from the Radioactive Materials Branch Director, Division of Radiological Health, MS State Dept. of Health:

"On November 18, 2004, licensee's RSO notified Division of Radiological Health/MS State Dept. of Health, of a Iodine-125 therapy misadministration. The prescribed treatment was for 145 gray to the prostate gland; however, due to an error concerning the coordinates, the treatment area was partially missed and resulted in a greater than 10 gray treatment to the rectum. The isotope was Iodine -125, 88 seeds with average activity of .300 millicuries, total activity of 26.8 millicuries. The patient was notified of the error and agreed to have the treatment performed again with no problems occurring. The RSO notified DRH after discussing the error with the authorized user and agreeing on corrective actions to prevent reoccurrence. At the present time, this is all the information we have received. I will update as soon as possible."

* * * UPDATE PROVIDED BY SMITH TO JEFF ROTTON AT 1738 EST ON 12/08/04 * * *

The following update information was provided via email from MS State Department of Health:

"The cause of the misadministration appears to be a misinterpretation to an ultrasound image which resulted in the needle being inserted in the wrong area. This caused a lower dose to be administered to the prostate gland greater than 20 % dose of the prescribed dose. Corrective actions will require a fIuoroscopticimage to verify the coordinates and confirm needle placement."

Notified R1DO (Anderson) and NMSS EO (Giitter)

To top of page
Hospital Event Number: 41249
Rep Org: HOSPITAL ALEJANDRO OTERO LOPEZ
Licensee: HOSPITAL ALEJANDRO OTERO LOPEZ
Region: 1
City: MANATI State: PR
County:
License #: 52-24916-01
Agreement: N
Docket:
NRC Notified By: DR. EDUARDO PASCUAL
HQ OPS Officer: JOHN KNOKE
Notification Date: 12/08/2004
Notification Time: 12:36 [ET]
Event Date: 12/08/2004
Event Time: [EST]
Last Update Date: 12/08/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
CLIFFORD ANDERSON (R1)
TOM ESSIG (NMSS)

Event Text

LOST BRACHYTHERAPY SEEDS

Licensee notified NRC that they have been performing an inventory of their I-125 brachytherapy seeds from 8/26/04 until 12/07/04. In September, the licensee discovered 4 seeds were missing along with a lead container. The licensee conducted a thorough search and interviewed hospital personnel that had access or used the brachytherapy seeds for patient treatment. Using a calculated activity range of 0.224 - 0.368 millicuries per seed with a possible decay factor of 4 half lives would give an estimated total remaining activity of 0.09 millicuries. As a preventive measure against future losses the licensee has placed a locked container in the Nuclear Medicine Hot Lab, and the licensee has restricted access to the locked container to only the lab physicist.

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