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

Event Notification Report for December 20, 2006

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/19/2006 - 12/20/2006

** EVENT NUMBERS **


43008 43051

To top of page
General Information or Other Event Number: 43008
Rep Org: WA DIVISION OF RADIATION PROTECTION
Licensee: UNIVERSITY OF WASHINGTON HARBORVIEW GAMMA KNIFE
Region: 4
City: SEATTLE State: WA
County:
License #: WN-M0219-1
Agreement: Y
Docket:
NRC Notified By: ARDEN SCROGGS
HQ OPS Officer: BILL HUFFMAN
Notification Date: 11/22/2006
Notification Time: 18:06 [ET]
Event Date: 11/16/2006
Event Time: [PST]
Last Update Date: 12/19/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VIVIAN CAMPBELL (R4)
JOSEPH HOLONICH (NMSS)

Event Text

AGREEMENT STATE - WASHINGTON - GAMMA KNIFE OVEREXPOSURE

The Washington State Department of Health (DOH) received a preliminary telephone report, November 22, from University of Washington, Harborview Gamma Knife, that a dose of 28 Grays had been administered to a patient. The exposure exceeded the prescribed exposure of 18 Grays by 10 Grays. The cause, thus far, is unknown. DOH is to receive a written report within 15 days.

The dose was administered by a Leksell Gamma System Model 24001 Type C gamma knife with 7,236 Curies of Co-60.

The patient or responsible relative has been notified.

The licensee is required to notify DOH within 24 hours. The notification is apparently several days late.

Washington State report number: #WA-06-066


* * * UPDATE PROVIDED VIA EMAIL FROM SCROGGS TO ROTTON AT 1955 EST ON 12/11/06 * * *

The State provided the following update information via email:

"The cause was stated by the licensee to be human error. The prescribing physician, apparently in a hurry to leave for the day, had prescribed 18 Gy. The physician then entered the Rx value into the computer treatment plan rather than having the medical physicist do it as is the usual procedure. The physician erroneously entered 28 Gy.

"The licensee stated the tumor undergoing treatment turned out to be larger than expected consequently the 28 Gy administered remains therapeutic with likely no ill-effects expected as a result of this incident.

"The treatment plan has been modified so that a similar event is less likely to occur. The progress of the patient is being closely watched by the licensee. DOH is expecting receipt of a written report from the licensee this week."

Notified the R4DO (Smith) and NMSS EO (Janosko).

* * * UPDATE PROVIDED VIA EMAIL FROM SCROGGS TO KOZAL AT 1841 EST ON 12/19/06 * * *

"The Department has received the licensee's written report of the incident and proposed corrective action. Corrective actions now include a verification process to ensure the correct treatment dose has been transferred from the treatment planning computer to the Gamma Knife computer prior to patient therapy. A plan signed by the treating oncologist, physicist, and neurosurgeon is now required. In addition the treating oncologist and physicist will verify and initial the prescription dose and isodose. Before a patient is treated, the nursing still will confirm: the patient's name/identity; the disease process; the disease site; the prescribed dose; and the prescribed isodose. These actions appear adequate at this time and will be reviewed during the Department's next visit to the facility.

"The effect to the individual is unknown at this time. However, it is expected that there will be minimal symptoms related to the larger radiation dose. A longer course of steroids than was initially planned may be prescribed."

Notified the R4DO (Whitten) and NMSS EO (Pierson).


A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

To top of page
General Information or Other Event Number: 43051
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: BOWSER-MORNER, INC.
Region: 3
City: DAYTON State: OH
County:
License #: OH31210580003
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: JOHN MacKINNON
Notification Date: 12/14/2006
Notification Time: 12:27 [ET]
Event Date: 12/13/2006
Event Time: 15:30 [EST]
Last Update Date: 12/14/2006
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JULIO LARA (R3)
GREG MORELL (NMSS)
ILTAB via email ()

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

OHIO AGREEMENT STATE REPORT - LOST/STOLEN MOISTURE DENSITY GAUGE

"Lost or stolen Troxler moisture density gauge from Toledo Office of licensee. Last physically seen on 11/28/06 in secure storage area. Was discovered missing when periodic inventory was being performed on 12/13/06. Gauge is not on licensee's premises or in possession of any current employees. Gauge has not been signed out in any utilization log since 11/28/06. Incident has been reported to Toledo Police Department. Licensee is still investigating. Troxler model 3440, S/N 023819, containing 10 mCi (millicuries) Cs-137 and 40 mCi Am-241. Reported to BRP on 12/13/06 at (approx.) 3: 30 PM."

Reference Number 2006-103

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

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.

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