Event Notification Report for January 04, 2007
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/03/2007 - 01/04/2007
General Information or Other
Event Number: 43078
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: ST. JAMES HOSPITAL AND HEALTH CENTER
Region: 3
City: OLYMPIA FIELDS State: IL
County:
License #: IL-01289-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: PETE SNYDER
Licensee: ST. JAMES HOSPITAL AND HEALTH CENTER
Region: 3
City: OLYMPIA FIELDS State: IL
County:
License #: IL-01289-01
Agreement: Y
Docket:
NRC Notified By: DAREN PERRERO
HQ OPS Officer: PETE SNYDER
Notification Date: 01/05/2007
Notification Time: 13:12 [ET]
Event Date: 01/04/2007
Event Time: 12:00 [CST]
Last Update Date: 03/13/2007
Notification Time: 13:12 [ET]
Event Date: 01/04/2007
Event Time: 12:00 [CST]
Last Update Date: 03/13/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JOHN MADERA (R3)
GREG MORELL (NMSS)
JOHN MADERA (R3)
GREG MORELL (NMSS)
AGREEMENT STATE REPPORT - MEDICAL DOSE TO WRONG LOCATION
"On January 4, St. James' Hospital and Health Center's medical physicist called to report that medical event had occurred involving a patient at their Cancer Center Institute. [The medical physicist] advised that a series of high dose rate (HDR) afterloading fractions using 10 Ci of Ir-192 that had been conducted on 11/29, 12/6, 12/13 and 12/20 had inadvertently caused the irradiation, not of the cancerous target intended but instead, a portion of the patient's inner thighs. The delivered radiation dose to the skin was 2,000 Rad and the dose to the intended treatment area was zero.
"[The medical physicist] indicated that the error had been identified as part of a 'chart audit' that was conducted prior to performing the next similar routine treatment of a subsequent patient. Computerized dosimetry planning records showed that although the prescribed treatment was to occur with an automated source travel distance of 120 cm, the actual data point used during the treatment phase was a travel distance of only 100 cm. The patient was asked to come to the hospital on the afternoon of January 4 for a consultation. During that visit the responsible authorized radiation oncologist confirmed reddening of the skin on both inners thighs of approximately 3 square centimeters. [The oncologist] indicated that the skin damage is a 'superficial ulceration with no necrosis of the tissue' and he expected healing to be completed in 2-4 weeks. [The oncologist] has made arrangements to meet with the patient weekly to monitor her progress during that time. HDR afterloader treatments have been rescheduled to occur next week."
The state also said that it appears that correct dose was administered to the wrong location because of a human error not an equipment malfunction.
Other pertinent data related to this event: Type of procedure: BRACHYTHERAPY, Intended Dose: 2000 RAD, Form of Radioactive Material: SEALED SOURCE, Radionuclide: IR-192, Activity: 10 Ci.
Equipment Information: Manufacturer: ALPH-OMEGA SERVICES VARIAN, Model Number: VS2000, Serial Number: 02011368001112006101.
The Illinois Emergency Management Agency will be following up on this incident. This report is IL report number 070001.
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.
* * *UPDATED ON 3/13/07 BY KOZAL TO EXPORT TO NRC PUBLIC WEBSITE* * *
"On January 4, St. James' Hospital and Health Center's medical physicist called to report that medical event had occurred involving a patient at their Cancer Center Institute. [The medical physicist] advised that a series of high dose rate (HDR) afterloading fractions using 10 Ci of Ir-192 that had been conducted on 11/29, 12/6, 12/13 and 12/20 had inadvertently caused the irradiation, not of the cancerous target intended but instead, a portion of the patient's inner thighs. The delivered radiation dose to the skin was 2,000 Rad and the dose to the intended treatment area was zero.
"[The medical physicist] indicated that the error had been identified as part of a 'chart audit' that was conducted prior to performing the next similar routine treatment of a subsequent patient. Computerized dosimetry planning records showed that although the prescribed treatment was to occur with an automated source travel distance of 120 cm, the actual data point used during the treatment phase was a travel distance of only 100 cm. The patient was asked to come to the hospital on the afternoon of January 4 for a consultation. During that visit the responsible authorized radiation oncologist confirmed reddening of the skin on both inners thighs of approximately 3 square centimeters. [The oncologist] indicated that the skin damage is a 'superficial ulceration with no necrosis of the tissue' and he expected healing to be completed in 2-4 weeks. [The oncologist] has made arrangements to meet with the patient weekly to monitor her progress during that time. HDR afterloader treatments have been rescheduled to occur next week."
The state also said that it appears that correct dose was administered to the wrong location because of a human error not an equipment malfunction.
Other pertinent data related to this event: Type of procedure: BRACHYTHERAPY, Intended Dose: 2000 RAD, Form of Radioactive Material: SEALED SOURCE, Radionuclide: IR-192, Activity: 10 Ci.
Equipment Information: Manufacturer: ALPH-OMEGA SERVICES VARIAN, Model Number: VS2000, Serial Number: 02011368001112006101.
The Illinois Emergency Management Agency will be following up on this incident. This report is IL report number 070001.
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.
* * *UPDATED ON 3/13/07 BY KOZAL TO EXPORT TO NRC PUBLIC WEBSITE* * *
Power Reactor
Event Number: 43076
Facility: COOPER
Region: 4 State: NE
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: STEVE WHEELER
HQ OPS Officer: JEFF ROTTON
Region: 4 State: NE
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: STEVE WHEELER
HQ OPS Officer: JEFF ROTTON
Notification Date: 01/04/2007
Notification Time: 23:46 [ET]
Event Date: 01/04/2007
Event Time: 17:43 [CST]
Last Update Date: 01/05/2007
Notification Time: 23:46 [ET]
Event Date: 01/04/2007
Event Time: 17:43 [CST]
Last Update Date: 01/05/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
TROY PRUETT (R4)
TROY PRUETT (R4)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
HIGH RANGE EFFLUENT RADIATION MONITORS DECLARED INOPERABLE DUE TO COMMON CAUSE FAILURE
"At 17:43 CST Cooper Nuclear Station declared the three High Range Kaman Effluent radiation monitors inoperable due to a common cause failure mechanism. The affected Kamans monitor the Elevated Release Point exhaust, the Turbine Building ventilation exhaust and the Radwaste/ Augmented Radwaste Building ventilation exhaust during accident conditions. The identified common failure mechanism results in the installed, movable calibration sources spuriously inserting into the monitors, causing them to indicted abnormally high.
"This condition is being reported under 50.72 as a loss of Emergency Preparedness Capabilities due to the potentially inaccurate indications of the High Range Building Exhaust radiation monitors and the Elevated Release Point Effluent radiation monitor."
The NRC Resident Inspector was notified of this event by the licensee.
"At 17:43 CST Cooper Nuclear Station declared the three High Range Kaman Effluent radiation monitors inoperable due to a common cause failure mechanism. The affected Kamans monitor the Elevated Release Point exhaust, the Turbine Building ventilation exhaust and the Radwaste/ Augmented Radwaste Building ventilation exhaust during accident conditions. The identified common failure mechanism results in the installed, movable calibration sources spuriously inserting into the monitors, causing them to indicted abnormally high.
"This condition is being reported under 50.72 as a loss of Emergency Preparedness Capabilities due to the potentially inaccurate indications of the High Range Building Exhaust radiation monitors and the Elevated Release Point Effluent radiation monitor."
The NRC Resident Inspector was notified of this event by the licensee.