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Event Notification Report for May 3, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/02/2007 - 05/03/2007

** EVENT NUMBERS **


43321 43325 43338

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General Information or Other Event Number: 43321
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: MEMORIAL MISSION HOSPITAL
Region: 1
City: ASHVILLE State: NC
County:
License #: 011-0091-6
Agreement: Y
Docket:
NRC Notified By: JAMES ALBRIGHT
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/26/2007
Notification Time: 18:19 [ET]
Event Date: 04/24/2007
Event Time: [EDT]
Last Update Date: 04/26/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES TRAPP (R1)
ROBERT PIERSON (NMSS)

Event Text

AGREEMENT STATE REPORT - NORTH CAROLINA - MISADMINISTRATION OF IODINE-131

The State provided the following information via facsimile:

The State of North Carolina was notified on 4/26/07 of a misadministration of diagnostic Iodine-131. The event involved a "misdrawn and mislabeled dose from Shertech Pharmacy in Ashville NC (NC licensee 011-1203-1). The written directive [from the hospital] was for 30 microcuries for a diagnostic thyroid scan but 33.9 millicuries was delivered labeled as 33.9 microcuries. Nuclear Medical Technologist at Memorial Mission missed the error because they read the numbers (33.9) but not the units (millicuries vs. microcuries). Dose was administered on 4/24/07 and the error was found on 4/26/07. Patient and physician notified. Licensee is following up with Shertech." No information is available on any potential medical impact of the misadministration on the patient.


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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General Information or Other Event Number: 43325
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee:
Region: 1
City: CHAPEL HILL State: NC
County:
License #: 068-0565-1
Agreement: Y
Docket:
NRC Notified By: UNC HOSPITALS
HQ OPS Officer: JASON KOZAL
Notification Date: 04/30/2007
Notification Time: 08:04 [ET]
Event Date: 04/20/2007
Event Time: 16:00 [EDT]
Last Update Date: 04/30/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES TRAPP (R1)
GREG MORELL (NMSS)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

"North Carolina Radioactive Materials Branch was notified by the radiation safety officer from UNC Hospitals of a possible misadministration involving the administration of MDS Nordion Yttrium 90 microspheres. The licensee initially contacted us immediately on the next business day following the patient administration, but was not certain at the time if the event was a misadministration because calculations and measurements had to be made to determine the percentage of the prescribed dose delivered. The licensee has determined that the patient only received approximately 72% of the prescribed dose (22.6 millicuries), which qualifies the event as a misadministration under current North Carolina Regulations.

"The misadministration occurred because of a leak in the administration set during delivery of the dose. The licensee has been asked to determine if the leak was because of an apparent manufacturing defect with the administration set, or the result of an assembly error by the licensee. The licensee will report the cause of the event in the Misadministration Report that must be submitted within 15 days of the event. No harm is expected to the patient because of this event. The patient's physician and authorized user will determine if an additional administration is necessary to account for the dose not delivered initially."

North Carolina Report Number: NC-07-02


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: 43338
Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-2
NRC Notified By: STEVE FULLER
HQ OPS Officer: JOHN KNOKE
Notification Date: 05/03/2007
Notification Time: 03:09 [ET]
Event Date: 05/03/2007
Event Time: 01:46 [EDT]
Last Update Date: 05/03/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
DANIEL HOLODY (R1)

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

Event Text

OFFSITE NOTIFICATION - RELEASE TO ENVIRONMENT

"Notified New Jersey Department of Environmental Protection of a release of sodium hypochlorite to the environment. The amount of sodium hypochlorite released was small (11.5 lbs) and well below the Federal (100 lbs) and state reportability limits for quantity."

Leak was from a hose on the chlorination system that supports the Service Water system.

The licensee notified the NRC Resident Inspector.

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Thursday, March 29, 2012