United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2006 > January 20

Event Notification Report for January 20, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/19/2006 - 01/20/2006

** EVENT NUMBERS **


42253 42263 42274

To top of page
!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!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)

To top of page
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

To top of page
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.

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