United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2008 > January 10

Event Notification Report for January 10, 2008

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/09/2008 - 01/10/2008

** EVENT NUMBERS **


43882 43887

Hospital Event Number: 43882
Rep Org: HACKLEY HOSPITAL
Licensee: HACKLEY HOSPITAL
Region: 3
City: MUSKEGON State: MI
County:
License #: 21-04125-01
Agreement: N
Docket:
NRC Notified By: CARLO SANTA ANNA
HQ OPS Officer: JEFF ROTTON
Notification Date: 01/04/2008
Notification Time: 15:20 [ET]
Event Date: 12/13/2007
Event Time: [EST]
Last Update Date: 01/04/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
PATRICK LOUDEN (R3)
GREG MORELL (FSME)

Event Text

PATIENT RECEIVED LESS THAT PRESCRIBED DOSE

"On 12/13/07, a patient was scheduled for a thyroid ablation with 100 mCi of NaI-131. The dose arrived with 3 capsules totaling 95.5 mCi. The nuc med tech was unaware that the package contained 3 capsules due to lack of visualization. The nuc med tech administered 1 capsule with the activity of 21.39 mCi of NaI-131. The package was sent back to the pharmacy with the remaining 2 capsules of approximately 70 mCi of NaI-131.

"The mistake was recognized the next morning. The radiologist was made aware of the situation and the patient notified immediately. The patient returned the morning of 12/14/07 and was administered the remaining 2 capsules totaling 69.7 mCi of NaI-131.

"Overall, the patient received a total of 91.09 mCi of Nal-131 over the course of 17 hours."

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.

To top of page
Power Reactor Event Number: 43887
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [3] [ ] [ ]
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: EDDIE NEVILLE
HQ OPS Officer: KARL DIEDERICH
Notification Date: 01/09/2008
Notification Time: 18:43 [ET]
Event Date: 01/09/2008
Event Time: 16:30 [EST]
Last Update Date: 01/09/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DAVID AYRES (R2)

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

Event Text

ERDS FAILED TO DISCONNECT DURING TEST

"Unit 3 was conducting a communication test of the Emergency Data Response System (ERDS). Following the test of the ERDS system, the ERDS modem would not disconnect with the NRC. The ERDS modem was disconnected in an effort to not overload the NRC communication system. The modem was disconnected at 16:30 EST on 1/9/2008. This constitutes a major loss of emergency assessment capability in accordance with 10 CFR 50.72 (b) (3) (xiii). The cause for the ERDS modem to auto-redial is not known. The ERDS link will be disconnected until the cause for the modem to auto-redial is determined and corrected. Follow-up NRC OC notification will be made when the ERDS link is re-established."

The vendor is on site.

The licensee has notified the resident inspector.

*** UPDATED ON 1/9/08 AT 2122 EST BY EDDIE NEVILLE TO KARL DIEDERICH ***

The ERDS modem has been repaired, tested satisfactorily, and returned to service.

The licensee will notify the resident inspector. R2DO (Ayres) notified.

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