Event Notification Report for October 03, 2005

OREGON AGREEMENT STATE REPORT - GAMMA KNIFE TREATMENT TO THE INCORRECT AREA OF THE PATIENT

The State provided the following information via facsimile:

"Doctor treated wrong Trigeminal nerve. Patient received 32 Gray before error was noted. Doctor informed patient of error then proceeded to treat correct nerve.

"In order to prevent a reoccurrence of this mistake, there will be three different double checks undertaken on the day of treatment. Prior to being sedated, the patient will be asked which side his or her pain is on. When the patient, is framed the nurse shall ask the neurosurgeon which side is to be treated. This will be verified with the patient. Lastly, just prior to treatment, both the neurosurgeon and the radiation oncologist will be once again asked which side is to be treated on the patient. This triple check system should prevent this mistake from happening again."

LOST GENERALLY-LICENSED DEVICE

Between 10/01/05 and 10/03/05, Continental Structural Plastics lost a small static eliminator. The device was attached to the barrel of an air gun and was being used to ionize plastic parts. The company searched for the material but was unable to locate it. It is thought that the material may have been inadvertently disposed of in the trash.

The device is a NRD Model P2021-8000 Nuclecel static eliminator containing a Po-210 ionization source. The company did not know the source strength, however these devices contain sources which are less than 10 milliCuries.

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks.

AGREEMENT STATE REPORT - TWO STOLEN MOISTURE DENSITY GAUGES

"Two Troxler Gauges stolen from storage container at temporary jobsite. NCDOT Gauge Manager called NC Radioactive Materials Branch at 7:45 AM to alert AGENCY. Only two gauges were stolen, and a torch was used to cut the security lock from the container.

"Location of job site: NC Highway 98 Bypass in Wake Forest, NC.

"Troxler Model 3450, Serial #298 - 8 mCi (milliCuries) CS-137, 40 mCi Am-241.

"Troxler Model 4640B, Serial #952 - 8 mCi Cs-137."

The Agreement State notified: NC PIO, FBI, SBI, Troxler, and the NCHP.

NC Incident # 05-34.

* * * UPDATE ON 10/3/2005 @ 11:25 FROM JEFFRIES TO ABRAMOVITZ * * *

"Troxler 3450 S/N 298 Cs-137 8 mCi S/N 750-5221 and Am-241:Be 40 mCi S/N 472355

"Troxler 4640B S/N 952 Cs-137 8 mCi S/N 50-9198

"Chain link fence was cut with bolt cutters. Gauges were stored in rear of tractor trailer storage unit. Torch and bolt cutters used to remove lock on trailer. Gauges with cases no longer on site. Both gauges had trigger locks and were locked in respective cases."

Contacted the R1DO (Rogge), the NMSSEO (Morell), and E-mailed TAS.


* * * UPDATE AT10:05 EST ON 11/16/05 FROM JEFFRIES TO KNOKE * * *

The State provided an update indicating one of the Troxler gauges (4640B, s/n 952) was recovered in a scrap metal yard. The source and shielding were intact and in place. Investigation is continuing.

Notified R1DO (Barkley), R2DO (Evans), NMSS (Burgess), and TAS (Whitney email)

OFFSITE NOTIFICATION MADE TO PENNSYLVANIA EMERGENCY MANAGEMENT AGENCY (PEMA)

"At 12:48 PM EST, the Main Control Room was notified that an individual needed medical assistance at the South Building. The individual was experiencing chest pains. An ambulance was requested to the site, and arrived on site at 13:17 PM. The individual is not contaminated and was transported offsite to a local hospital at 13:35 PM. PEMA was notified of the incident.

"This requires a voluntary report due to the offsite notification on an emergency vehicle responding to the site."

The NRC Resident Inspector was notified of this voluntary notification.

AGREEMENT STATE REPORT ON A SOURCE OF UNKNOWN ORIGIN FOUND AT METAL PROCESSOR

The State representative reported that scrap metal received by a metal processor in Sand Springs, OK, set off the facility's gate radiation monitor. Investigation into the alarm determined that the radiation was coming from a foil source of unknown origin. The source dimensions are 3 inches by 1/2 inch with a contact reading (using a Ludlum Model 3) of 200 mR/hr. The scrap metal processor notified the State which dispatched inspectors to the site.

The State found that the source also had loose surface contamination. Investigation has determined that four individuals had handled the source. The State was able to contact one of those individuals and a survey of the individual revealed no indication of contamination. The State has not yet been able to contact the other three people involve in handling the source. The source has been wrapped in lead shielding material and secured in a safe location. The State plans to perform a Gamma Spec analysis of the source to determine the isotope. The investigation into the origin of the source has been unproductive so far. It appears that the scrap metal came from a intermediary scrap metal dealer.

* * * UPDATE ON 10/5/05 @ 15:20 FROM SAMPSON TO ABRAMOVITZ * * *

The source (foil) was determined to be Radium-226. The Curie content was not determined but was estimated to be in the micro Curie range. The loose contamination was not found on any other surfaces, only on the test swipe. The four individuals who contacted this source were contacted and an estimate of their dose is in progress.

Notified R4DO D. Graves.

FITNESS FOR DUTY

"A non--licensed contractor supervisor had a Medical Review Officer (MRO) determined positive for alcohol during a "for cause" test. The employee's access to the plant has been terminated."

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

Contact the Headquarters Operation Officer for additional details.

MEDICAL EVENT - SOME BRACHYTHERAPY SEEDS ADMINISTERED TO WRONG SITE

"l am calling per 10 CFR 35.3045 to notify you of a possible medical event at the VA Medical Center, Philadelphia, Pennsylvania. On October 3, 2005 a permanent implant prostate brachytherapy procedure was performed at the medical center. A written directive prescribed 90 Iodine 125 seeds to be implanted in the patient's prostate.

"However, 45 of the seeds were implanted mistakenly in bladder. The seeds were recovered from the bladder prior to completion of the procedure in the operating room.

"The written directive was revised by the authorized user prior to completion of the procedure in the operating room to document the actual number of seeds implanted in the prostate (45).

"Based on dosimetry calculations performed October 4, 2005, a medical event may have occurred since the dose to the prostate and other tissues may differ from that originally prescribed in the written directive by values greater than those given in 10 CFR 35.3045.

"These circumstances appear to be similar to a previously reported event (Event No. 39586), which NRC ultimately decided did not represent a medical event.

"However, the NHPP has decided conservatively to perform an on-site review at the medical center next week to assess the particular circumstances of this event."

At the time of this report the licensee did not know why the event happened but will be investigating to determine the cause and the significance on 10/13/2005. The licensee stated that the patient was notified of the situation.

* * * RETRACTION AT 14:05 EST ON 2/3/2006 FROM GARY WILLIAMS TO ABRAMOVITZ * * *

"Based on our discussions with NRC Region III, the circumstances for event do not meet the definition in 10CFR35.3045 as a medical event."

Contacted the R1DO (Meyer), R3DO (Riemer), and NMSS EO (Morell).