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Event Notification Report for March 22, 2007

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Event Reports For
03/21/2007 - 03/22/2007

** EVENT NUMBERS **


43252 43253

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General Information or Other Event Number: 43252
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: DOCTORS HOSPITAL, INC
Region: 1
City: CORAL GABLES State: FL
County:
License #: 3823-2
Agreement: Y
Docket:
NRC Notified By: STEVE FURNACE
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/20/2007
Notification Time: 10:57 [ET]
Event Date: 03/05/2007
Event Time: [EDT]
Last Update Date: 03/20/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1)
GREG MORELL (FSME)

Event Text

AGREEMENT STATE - MEDICAL EVENT RELATED TO DOSE LESS THAN 20% PRESCRIBED

"Upon quality review a misadministration was discovered by hospital staff on March 3, 2007; the actual medical procedure was performed on January 23, 2007. It is estimated that patient was administered a dose less than 20% of the intended dose. State was notified on 19 March 2007. This incident is referred to [the State's] radioactive materials [office] for investigation."

The misadministration involved a Gamma Knife. A quality review by the licensee confirmed that a treatment dose was prescribed as
- 40% of maximum dose equivalent equals 11Gy; but was calculated as - 50% of maximum dose equals 11Gy.

This discrepancy resulted in the administration of a dose that was 20% less than intended.

State Report FL07-046

* * * Update on 03/20/07 at 1408 EDT via e-mail from FSME (C. Flannery) to MacKinnon * * *

This event has been reviewed and determined to be a medical event. Immediate release to the public is authorized.

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.

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Power Reactor Event Number: 43253
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: TERRY BACON
HQ OPS Officer: JOHN MacKINNON
Notification Date: 03/21/2007
Notification Time: 20:05 [ET]
Event Date: 03/21/2007
Event Time: 18:45 [CDT]
Last Update Date: 03/21/2007
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 Y 100 Power Operation 100 Power Operation
2 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATIONS MADE TO STATE , LOCAL AND COUNTY AGENCIES

"The Prairie Island Nuclear Plant has a turbine building sump that collects water from the secondary side of the plant and this water contains trace levels of tritium. When we normally discharge the water from the sump, it is either sent to the river or to a permitted area on plant property. Earlier today, the discharge was lined up to the permitted area on plant property. The end of the line was frozen, causing approximately 100 - 150 gallons of the water to be diverted to a non-permitted area inside the plant property.

"This notification is being made due to the notification of offsite agencies (state , local and county)."

The NRC Resident Inspector was notified of this event by the licensee.

Page Last Reviewed/Updated Thursday, March 29, 2012
Thursday, March 29, 2012