U.S. Nuclear Regulatory Commission Operations Center Event Reports For 01/19/2006 - 01/20/2006 ** EVENT NUMBERS ** | !!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!! | Hospital | Event Number: 42253 | Rep Org: NEW BRITAIN GENERAL HOSPITAL Licensee: NEW BRITAIN GENERAL HOSPITAL Region: 1 City: NEW BRITAIN State: CT County: HARTFORD License #: 06-02388-01 Agreement: N Docket: NRC Notified By: CELESTE MAJEK HQ OPS Officer: JOHN MacKINNON | Notification Date: 01/12/2006 Notification Time: 10:18 [ET] Event Date: 01/11/2006 Event Time: 09:15 [EST] Last Update Date: 01/19/2006 | Emergency Class: NON EMERGENCY 10 CFR Section: 35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE | Person (Organization): RICHARD CONTE (R1) GREG MORELL (NMSS) | Event Text LICENSEE DID NOT HAVE A WRITTEN DIRECTIVE BEFORE ADMINISTERING A DIAGNOSTIC WHOLE BODY SCAN. A patient had a physicians order to perform a diagnostic whole body scan but the two technologists over-looked that the patient did not have a written directive to give the patient 4.1 millicuries of Iodine-131. The patient got the correct dose of Iodine-131 for his diagnostic whole body scan. The licensee stated that they were operating under Departmental Protocol for Thyrogen Whole Body Iodine doses. * * * RETRACTION FROM C. MAJEK TO W. GOTT AT 1307 ON 01/19/06 * * * Based on discussions with NRC personnel, the licensee does not consider this to meet the criteria of a medical event. This event is retracted. Notified R1DO (C. Hott) and NMSSEO (G. Morell) | General Information or Other | Event Number: 42263 | Rep Org: LOUISIANA RADIATION PROTECTION DIV Licensee: MARY BIRD PERKINS CANCER CENTER Region: 4 City: BATON ROUGE State: LA County: License #: LA-2651-L01 Agreement: Y Docket: NRC Notified By: MIKE HENRY HQ OPS Officer: JEFF ROTTON | Notification Date: 01/17/2006 Notification Time: 15:30 [ET] Event Date: 11/22/2005 Event Time: [CST] Last Update Date: 01/17/2006 | Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE | Person (Organization): WILLIAM JONES (R4) LAWRENCE KOKAJKO (NMSS) | Event Text AGREEMENT STATE REPORT - MEDICAL EVENT The State provided the following information via facsimile: "The patient was planned to receive an HDR brachytherapy dose of 750 cGy in a single fraction to a distance of 1.0 cm beyond the active dwell positions in the right lung. A catheter was inserted in the right bronchus on November 22, 2005 for the treatment. The catheter was marked at the entrance of the nostril and taped to the nose and face. The patient was then taken to CT for the treatment planning. The treatment plan was developed and approved. The patient was treated in a linear accelerator vault. Prior to treatment, a dummy wire was placed into the catheter and a megavoltage portal image was taken to confirm placement of the catheter. The radiation oncologist believed that he had verified the catheter placement from the portal image. The catheter was connected to the HDR unit and the treatment was performed. At the conclusion of the treatment, the prescribing physician and nurse entered the treatment room to remove the catheter from the patient. At that time it was discovered that the catheter was not fully inserted into the patient's lung. The mark that was put on the catheter during the planning was 15 cm outside of the nose. Apparently the catheter had become loose from the tape. According to the prescribing physician the dose used for this treatment was not enough to produce any significant sequalae in the upper thorax and neck region. The patient was informed on 11/22/05. External beam therapy will be used for the missing dose to the lung. Some procedures have been modified to prevent this from reoccurring." LA Event Report ID No: LA050009 | Power Reactor | Event Number: 42274 | Facility: HADDAM NECK Region: 1 State: CT Unit: [1] [ ] [ ] RX Type: [1] W-4-LP NRC Notified By: ROSEMARY PEKAROVIC HQ OPS Officer: MARK ABRAMOVITZ | Notification Date: 01/19/2006 Notification Time: 14:00 [ET] Event Date: 01/19/2006 Event Time: 13:04 [EST] Last Update Date: 01/19/2006 | Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(2)(xi) - OFFSITE NOTIFICATION | Person (Organization): CHRIS HOTT (R1) | Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | 1 | N | N | 0 | Decommissioned | 0 | Decommissioned | Event Text OFFSITE NOTIFICATION OF MINOR OIL SPILL An excavator leaked approximately three cups of oil within the site boundary. The spill created a sheen on water in the discharge canal. The spill was contained and the soil and water were cleaned up. The licensee notified the State Police, Department of Environmental Protection, and the Coast Guard. | |