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Event Notification Report for May 11, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/10/2006 - 05/11/2006

** EVENT NUMBERS **


42523 42556 42563 42564 42565 42566

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General Information or Other Event Number: 42523
Rep Org: ARKANSAS DEPARTMENT OF HEALTH
Licensee: CENTRAL ARKANSAS RADIATION THERAPY INSTITUTE
Region: 4
City: LITTLE ROCK State: AR
County:
License #: ARK654BP12-08
Agreement: Y
Docket:
NRC Notified By: KIM WIEBECK
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/24/2006
Notification Time: 14:11 [ET]
Event Date: 04/21/2006
Event Time: [CDT]
Last Update Date: 05/10/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4)
GREG MORELL (NMSS)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

The State provided the following information via email:

"On April 21, 2006, the Radioactive Materials Program of Arkansas Department of Health and Human Services was notified by Central Arkansas Radiation Therapy Institute, ARK-654-BP-12-08, located in Little Rock, of a possible misadministration (medical event), which had been identified during the post-implant CT of a prostate implant patient. Based upon the CT scan, the facility determined that the I-125 seeds had been implanted in the incorrect area. The post-implant treatment plan generated on April 24, 2006, indicated that a dose greater than 50 Rem had been delivered to an unintended area of tissue.

"The licensee and Department will continue to investigate this event. A final written report regarding this misadministration (medical event) will be submitted within 15 days.

"NRC Region IV was notified of the potential misadministration on April 21, 2006."

* * * UPDATE RECEIVED FROM THE STATE (KIM C. WIEBECK) VIA E-MAIL TO JOE O'HARA ON 5/10/06 AT 0938 * * *

"As previously reported, on April 21, 2006 CARTI notified Arkansas Department of Health and Human Services of a misadministration (medical event) that occurred during an I-125 prostate seed implant. The final written report was received on May 9, 2006.

"The post-implant dosimetry imaging determined that the 84, I-125 seeds with average activity of 0.219 mCi on March 28, 2006, were misplaced approximately 4 cm inferior to their intended position. The post-implant dose calculation determined that a dose of 108 Gy, which was consistent with the prescribed dose, had been delivered to the incorrect area.

"Root cause was determined to be two-fold. First was the inability prior to implant to place a Foley catheter to fill the bladder allowing a clear definition of the base of the prostate gland. Second was the human error in clear delineation of the prostate gland and alignment of the template prior to seed implant.

"The patient will require further treatment of the prostate gland via re-implantation in order to deliver the appropriate dose. Any effects from the misadministration (medical event) may not manifest immediately and may be difficult to distinguish from the effects of the external beam IMRT treatment that the patient received prior to the March 2006 implant.

"The licensee has implemented a new policy for inexperienced urologists that requires placement of the Foley catheter prior to implanting seeds, thus ensuring clear definition of the base of the prostate and the urethra."

Notified R4DO(Powers) & NMSS EO(Morell)

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General Information or Other Event Number: 42556
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: 21ST CENTURY ONCOLOGY
Region: 1
City: CORAL SPRINGS State: FL
County:
License #: 2667-1
Agreement: Y
Docket:
NRC Notified By: MARK SEIDENSTRICKER
HQ OPS Officer: BILL GOTT
Notification Date: 05/05/2006
Notification Time: 13:49 [ET]
Event Date: 03/31/2006
Event Time: [EDT]
Last Update Date: 05/05/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RONALD BELLAMY (R1)
TIM HARRIS (NMSS)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

An 80 year old white female undergoing a Mammosite Brachytherapy (Nuclear Tron V2 model 31662) procedure utilizing Ir-192 source received less than 30% of the prescribed dose of 3400 centi-gray (cGy) (accumulated dose). An incorrect figure was entered into the computer causing the source to stay back 6 cm from the intended position and hence dosing an unintended area of approximately 2 cm with 3 times the prescribed dose of 10,000 cGy. The treatment was given 2 times a day for five days from March 31 to April 7, 2006. The patient saw the attending physician for follow-up on May 2, 2006. The physician discovered the patients skin abnormally red. He contacted the Medical Physicist who investigated and discovered the input error. The physician, patient and the patients family were notified. The patient is well and is being treated for erythema.

Florida Incident number: FL 06-062

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Power Reactor Event Number: 42563
Facility: SALEM
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: PAUL ABBOTT
HQ OPS Officer: PETE SNYDER
Notification Date: 05/10/2006
Notification Time: 04:36 [ET]
Event Date: 05/10/2006
Event Time: 02:15 [EDT]
Last Update Date: 05/10/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
ANTHONY DIMITRIADIS (R1)
S. BAUMGARTNER (NRC)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 100 Power Operation 100 Power Operation

Event Text

NOTIFICATION OF OFFSITE AMMONIA AND HYDRAZINE RELEASE

"A notification was made to the New Jersey Department of Environmental Protection of a discharge of approximately 2000 gallons of water containing 30 parts per million (ppm) of hydrazine and 200 ppm of ammonia to the Delaware river, via the storm drain system. The source of the water was a relief valve on the Unit 1 Condensate System that resulted in the overflow of the condensate polisher building sump. The water migrated from the building to the storm drain system. The discharge was terminated at the time of discovery.

"There was no equipment out of service that contributed to this event and there were no personnel injuries or radiological occurrences associated with this event."

The licensee will notify the NRC Resident Inspector.

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Hospital Event Number: 42564
Rep Org: JAMESON HOSPITAL
Licensee: JAMESON HOSPITAL
Region: 1
City: NEW CASTLE State: PA
County:
License #: 37-01146-03
Agreement: N
Docket:
NRC Notified By: DOUG DANKO
HQ OPS Officer: JOE O'HARA
Notification Date: 05/10/2006
Notification Time: 10:57 [ET]
Event Date: 05/08/2006
Event Time: 08:36 [EDT]
Last Update Date: 05/10/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2202(b)(1) - PERS OVEREXPOSURE/TEDE >= 5 REM
Person (Organization):
ANTHONY DIMITRIADIS (R1)
GREG MORELL (NMSS)

Event Text

POTENTIAL PERSONNEL OVEREXPOSURE

Jameson Hospital in New Castle, PA. reported that one of its physicians had a film badge reading of 9,218 mRem deep dose. The film badge was issued to the physician on 11/5/05 and processed by Global Dosimetry approximately four months after being issued. According to the radiation safety officer, the physician is a licensed anesthesiologist and was exposed to radioactive sources for approximately 3 hours per day providing fluoroscopy imaging procedures to patients spinal cords in a laboratory environment over the four month period. The only recorded dose for the physician this calendar year is 45 mRem from March 2006 to April 2006. There are no other individuals who worked in the same area as the affected physician reporting any high film badge readings. Jameson Hospital has notified the physician, initiated a root cause investigation, and is reprocessing the film badge to determine the root cause.

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Power Reactor Event Number: 42565
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: DOUG SMITH
HQ OPS Officer: STEVE SANDIN
Notification Date: 05/10/2006
Notification Time: 16:54 [ET]
Event Date: 05/10/2006
Event Time: 15:45 [CDT]
Last Update Date: 05/10/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
PATTY PELKE (R3)

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

Event Text

OFFSITE NOTIFICATION AND PRESS RELEASE ISSUED DUE TO DISCOVERY OF ASBESTOS MATERIAL DURING MAINTENANCE

"This notification is being made in accordance with 10CFR50.72(b)2(xi) due to a press release being issued. The Nuclear Management Company [NMC] will be issuing a press release regarding maintenance activities on a non-safety related, non-radioactive system that will state:

'During work on a plant equipment modification at Prairie Island Nuclear Plant Unit 1 last week, some gasket material being removed was found to contain asbestos. Prairie Island Unit 1 is in the midst of a refueling outage.

'As soon as site management became aware of the concern for potential asbestos containing material, work on the project was suspended, according to Nuclear Management Co., which operates the plant. The air immediately was monitored and tested according to Minnesota Clean Air requirements. The results were well below regulatory limits. However, results from additional testing on surfaces by a certified lab indicated detectable levels of asbestos on some surfaces in the immediate area.

'Trained asbestos workers are performing a complete clean-up of the affected area.

'NMC and its contractor are taking precautionary actions for any employee with a concern for potential exposure. This includes offering an optional asbestos exposure examination in accordance with federal Occupational Safety and Health Administration (OSHA) guidelines.

'Prairie Island's two reactors near Red Wing, Minn., generate 1,076 megawatts of electricity, enough to power one in five homes and businesses in the Upper Midwest. Xcel Energy owns the plant, which is one of six reactors operated by Nuclear Management Company, headquartered in Hudson, Wis.'"

Unit 1 is currently defueled. The licensee informed state/local agencies/nearby tribal entity and the NRC Resident Inspector.

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Hospital Event Number: 42566
Rep Org: BOZEMAN DEACONESS HOSPITAL
Licensee: BOZEMAN DEACONESS HOSPITAL
Region: 4
City: BOZEMAN State: MT
County:
License #: 25-10994-04
Agreement: N
Docket:
NRC Notified By: RON THARP
HQ OPS Officer: MIKE RIPLEY
Notification Date: 05/10/2006
Notification Time: 17:02 [ET]
Event Date: 05/09/2006
Event Time: 12:00 [MDT]
Last Update Date: 05/10/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(3) - DOSE TO OTHER SITE > SPECIFIED LIMITS
Person (Organization):
DALE POWERS (R4)
THOMAS ESSIG (NMSS)

Event Text

MEDICAL EVENT - DOSE TO UNINTENDED SITE

A medical event was identified during the post-implant CT scan of a prostate implant patient. A total of 88 seeds were implanted (30.3 milliCuries total). The CT scan confirmed that most of the seeds were located in an area surrounding the urethra instead of the prostrate. The patient's physician has been informed. The licensee will continue to investigate this event.

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