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Event Notification Report for May 15, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/14/2007 - 05/15/2007

** EVENT NUMBERS **


43356 43362 43363

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General Information or Other Event Number: 43356
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: ST ANTHONY HOSPITAL
Region: 4
City: OKLAHOMA CITY State: OK
County:
License #: OK-01428-03
Agreement: Y
Docket:
NRC Notified By: MIKE BRODERICK
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/11/2007
Notification Time: 10:55 [ET]
Event Date: 04/27/2007
Event Time: [CDT]
Last Update Date: 05/14/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4)
SCOTT FLANDERS (FSME)
GREG MORELL (FSME)

Event Text

AGREEMENT STATE REPORT MEDICAL EVENT - PATIENT UNDERDOSE

A patient was to receive 150 mCi of I-131 for thyroid cancer on April 27, 2007. The dose was two capsules in a single vial (tube). The intended dose activity was reported to be correct. The patient was presented with the vial containing the dosage. The patient took the dosage. The vial and lead container were placed in storage. On May 9, 2007 a nuclear medical technician discovered a capsule in the vial. The patient had received one-half of the intended dose. The technician reported the discovery to the RSO who reported the incident to the Oklahoma Radiation Management Section supervisor (May 9, 2007 at 5:26 p.m.) by e-mail. Radiation Management Section investigators interviewed St. Anthony Hospital nuclear medicine technicians on May 10, 2007. The patient will be notified. The RSO will submit a written report within 15 days of the initial report. The unused capsule will decay-in-storage.

State of Oklahoma Medical Event reportable under 10CFR35.3045(a)(1)(i)
Event Cause Failure to verify that the entire dose was administered

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 BY E-MAIL AT 07:01 ON 5/14/2007 FROM C. FLANNERY TO M. ABRAMOVITZ * * *

"This event has been reviewed and determined to be a reportable medical event."

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Hospital Event Number: 43362
Rep Org: SENTARA CAREPLEX HOSPITAL
Licensee: SENTARA CAREPLEX HOSPITAL
Region: 1
City: HAMPTON State: VA
County:
License #: 45-09087-01
Agreement: N
Docket:
NRC Notified By: SANDY WOLFF
HQ OPS Officer: JOHN MacKINNON
Notification Date: 05/14/2007
Notification Time: 08:48 [ET]
Event Date: 04/17/2007
Event Time: 12:00 [EDT]
Last Update Date: 05/14/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
PAT FINNEY (R1)
GREG MORELL (FSME)

Event Text

PATIENTS THYROID CONTAINING 200 MICROCURIES OF IODINE-131 INADVERTENTLY SHIPPED FROM HOSPITAL

On March 30, 2007 a patient was given 5 millicuries of Iodine-131 to his thyroid. On April 2, 2007 the patients thyroid was removed and processed by the Lab. The thyroid was kept by the Sentara CarePlex Hospital located in Hampton, VA for 2 weeks in case there are pathology questions. On either April 16 or 17, 2007 the thyroid was sent to Stericycle Autoclave Facility located in Baltimore, MD. Stericycle Autoclave Facility, received the thyroid on April 17, 2007 and discovered that the thyroid was still radioactive. Sentara CarePlex was informed of this and they contacted one of their contractor RSOs. The RSO picked up the thyroid and has stored it for future disposition. The thyroid was calculated to have 200 microcuries of Iodine-131 as of April 17, 2007.

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Power Reactor Event Number: 43363
Facility: PERRY
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: ROBERT KIDDER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/15/2007
Notification Time: 01:53 [ET]
Event Date: 05/15/2007
Event Time: 00:58 [EDT]
Last Update Date: 05/15/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
MARK RING (R3)
ELMO COLLINS (NRR)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 30 Power Operation 0 Hot Shutdown

Event Text

REACTOR SCRAM DURING TESTING

"An automatic reactor scram occurred due to lowering reactor water level. Digital feedwater tuning activities were in progress at the time of the scram. All systems functioned as designed. The reactor water level has been restored to normal level band. The plant is stable in Hot Shutdown. There were no ECCS injections."

At the time of the scram, the feedwater pump was in manual control for feedwater tuning. When water level started going down quickly, the operator was not able to restore sufficient feedwater flow before the level 3 (water level low) actuation. All control rods fully inserted on the scram. No valves repositioned and no safety or relief valves lifted after the scram. Reactor water level is being maintained with the motor feed pump and decay heat is being removed to the main condenser. The plant is in the normal shutdown electrical lineup. Reactor pressure is 509 psi and stable.

The licensee notified the NRC Resident Inspector.

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Thursday, March 29, 2012