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Event Notification Report for March 30, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/29/2007 - 03/30/2007

** EVENT NUMBERS **


43256 43258 43264

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital Event Number: 43256
Rep Org: LANCASTER GENERAL HOSPITAL
Licensee: LANCASTER GENERAL HOSPITAL
Region: 1
City: LANCASTER State: PA
County:
License #: 37-1186-01
Agreement: N
Docket:
NRC Notified By: ANTHONY MONTAGENESE
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/23/2007
Notification Time: 19:30 [ET]
Event Date: 03/23/2007
Event Time: 13:00 [EDT]
Last Update Date: 03/28/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
MEL GRAY (R1)
E. WILLIAM BRACH (FSME)

Event Text

POTENTIAL OVEREXPOSURE INVOLVING BRACHYTHERAPY SOURCE

At 1300 hours on 3/23/07, a male patient received I-125 seed implants for treatment of prostate cancer. The RSO received a call at approximately 1730 hours from the Radiation Oncologist Physicist who had identified that the wrong units were input into the dose planning computer. This resulted in a potential overexposure. A CAT scan is scheduled for Monday, 3/26/07, to verify source placement and more accurately calculate the overexposure. At this time, the preliminary information provided indicates a prescribed dose of 145 Gray with an estimated dose delivery of 155 Gray. The licensee does not believe that there will be any adverse effects to the patient. Following the more accurate calculation the licensee will review whether this notification meets the reporting criteria.

The licensee has notified the prescribing physician of the error.

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.

* * * UPDATE ON 3/28/07 AT 1417 FROM MONTAGENESE TO SNYDER * * *

This event is retracted by the licensee. Since the time of the original notification the licensee has established, by dosimetry readings, that the exposure was below the reporting criteria.

Notified R1DO (Dimitriadis) and FSME EO (Morell).

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General Information or Other Event Number: 43258
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: CALIFORNIA SURGERY CENTER
Region: 4
City: Bakersfield State: CA
County:
License #: 6833-15
Agreement: Y
Docket:
NRC Notified By: BARBARA HAMRICK
HQ OPS Officer: BILL HUFFMAN
Notification Date: 03/27/2007
Notification Time: 17:52 [ET]
Event Date: 03/19/2007
Event Time: [PDT]
Last Update Date: 03/27/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JACK WHITTEN (R4)
LARRY CAMPER (FSME)

Event Text

AGREEMENT STATE - CALIFORNIA - MEDICAL MISADMINISTRATION

The State provided the following information via facsimile:

"On March 16, 2007, the licensee initiated a 'Mammosite' treatment of a patient, with a total prescribed dose of 3400 cGy (3400 rad) to be delivered in 10 fractions of 340 cGy (340 rad) each, over the course of 5 days, using a Nucletron, Model 105.999 HDRA with 4.1 Ci Ir-192 (as of the first day of treatment). The first five fractions were delivered uneventfully. During the last five fractions, the radiation therapy technologist accidentally imported the wrong treatment plan, resulting in an underdose to the treatment area. The dwell position of the source was actually fully outside of the patient, so the tumor received effectively no dose. The licensee is calculating the skin and whole body dose to the patient, but currently estimates it will not have an adverse affect upon the patient. The patient and referring physician have been notified, and re-treatment has been scheduled to begin tomorrow. This event was discovered upon review of the patient's chart when the patient returned for a follow-up exam. The licensee will provide a written report of the event within 15 days."

CA Report #032707

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: 43264
Facility: MILLSTONE
Region: 1 State: CT
Unit: [ ] [2] [3]
RX Type: [1] GE-3,[2] CE,[3] W-4-LP
NRC Notified By: ROBERT WHITE
HQ OPS Officer: JEFF ROTTON
Notification Date: 03/29/2007
Notification Time: 12:08 [ET]
Event Date: 03/29/2007
Event Time: 09:00 [EDT]
Last Update Date: 03/29/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
ANTHONY DIMITRIADIS (R1)

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

Event Text

OFFSITE NOTIFICATION TO LOCAL LAW ENFORCEMENT

Licensee requested offsite assistance from local police department. Contact Headquarters Operations Officer for additional details.

The licensee notified the NRC Resident Inspector.

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