| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
07/10/2008 - 07/11/2008 ** EVENT NUMBERS ** |
 | Hospital | Event Number: 44219 | Rep Org: VA NATIONAL HEALTH PHYSICS PROGRAM
Licensee: VA MEDICAL CENTER, PHILADELPHIA
Region: 1
City: PHILADELPHIA State: PA
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: EDWIN LEIDHOLDT
HQ OPS Officer: JEFF ROTTON | Notification Date: 05/16/2008
Notification Time: 20:30 [ET]
Event Date: 05/05/2008
Event Time: 09:30 [EDT]
Last Update Date: 07/10/2008 | Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
| Person (Organization):
PAUL KROHN (R1)
HIRONORI PETERSON (R3)
REBECCA TADESSEE (FSME)
| Event Text POTENTIAL MEDICAL EVENT DUE TO USE OF I-125 SEEDS OF LOWER APPARENT ACTIVITY THAN INTENDED
"Notification of a possible medical event per 10 CFR 35.3045 - a brachytherapy procedure in which the administered dose may differ from the prescribed dose by more than 0.5 gray to an organ and the total dose delivered may differ from the prescribed dose by twenty percent or more.
"Permittee: VA Medical Center, Philadelphia, PA
"Event: The event occurred on May 5, 2008, and was discovered on May 15, 2008.
"Description: A permanent implant prostate brachytherapy procedure was performed on May 5, 2008, using I-125 seeds. Seeds of a lower apparent activity than intended were mistakenly ordered and implanted. A CT scan of the patient was performed on May 6, 2008, and a postplan was performed on May 15, 2008. The D90 dose, calculated from the postplan, was less than eighty percent of the prescribed dose. Postplans based on CT scans performed approximately one month after an implant, when swelling from the procedure has partially resolved, are believed to provide more accurate assessment of dose to the prostate. It is intended to obtain another CT scan and postplan at about this time to better assess the prostate dose. The permittee intends to make a determination at that time regarding whether a medical event did occur. The permittee will complete a causal analysis and implement procedural changes to prevent a recurrence before any additional brachytherapy procedures are performed.
"Effect on Patients: The VA is continuing to evaluate this event. At this time, adverse effects to the patient are not expected.
"Patient notification: The permittee is ensuring that the referring physicians and patients were notified.
"Licensee will notify the NRC Project Manager, Cassandra Frasier, of NRC Region III."
* * * UPDATE ON 6/06/08 AT 18:16 EDT FROM LEIDHOLDT TO HUFFMAN * * *
"This is an amendment to NRC Event Number 44219 and is a notification of possible medical events per 10 CFR 35.3045.
"The VHA National Health Physics Program notified the NRC Operations Center on May 16, 2008, of a possible medical event at the VA Medical Center, Philadelphia, Pennsylvania, involving transperineal permanent seed implant prostate brachytherapy.
The VHA National Health Physics Program initiated a reactive inspection on May 28, 2008. As part of this reactive inspection, the medical center was requested to review additional brachytherapy procedures.
Based on a review of other brachytherapy procedures performed between February 1, 2007, and May 31, 2008, the medical center identified an additional four brachytherapy procedures that may be medical events because the D90 doses, determined from post-implant CT scans, were more than 20 percent less than the prescribed doses. The procedures are still under evaluation and a final determination has not been made.
VHA is continuing to evaluate these possible medical events. At this time, adverse effects to the patients are not expected.
If these patient procedures are determined to be medical events, the medical center will ensure that the referring physicians and patients are notified.
VHA has notified NRC, Region III (NRC Project Manager, Cassandra Frasier).
R1DO (Henderson), R3D(Pelke), and FSME (Chang) notified.
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 FROM E. LIEDHOLDT TO JOE O'HARA AT 2009 ON 6/12/08 * * *
"This is an amendment to NRC Event Number 44219 and is a notification per 10 CFR 35.3045 of additional possible medical events.
"VHA notified the NRC Operations Center on May 16, 2008, of a possible medical event at the VA Medical Center, Philadelphia, Pennsylvania, involving transperineal permanent seed implant prostate brachytherapy.
"VHA initiated a reactive inspection on May 28, 2008. As part of this reactive inspection, the medical center was requested to review additional brachytherapy procedures.
"VHA provided an initial update on June 6, 2008. This update reflects the most current information.
"The medical center has identified 45 brachytherapy procedures that could be medical events because the D90 doses, determined from post-implant CT scans, were more than 20 percent less than the prescribed doses. The procedures are still under evaluation and a final determination has not been made.
"We note that the medical center prescribes a dose of 160 gray instead of the more common 145 gray and that the number of possible events would be substantially less if the definition of a medical event were based upon the delivered dose instead of a percent of prescribed dose.
"Furthermore, the medical center determines D90 doses from post-implant CT scans performed the day after the procedures. Prostate swelling may cause the doses assessed from these scans to underestimate the delivered D90 doses.
"The permanent implant brachytherapy program has been suspended by the medical center director and an external review will be performed.
"Effect on patients:
"VHA is continuing to evaluate these possible medical events. At this time, adverse effects to the patients are not expected.
"Patient notification:
"If these patient procedures are determined to be medical events, the medical center will ensure that the referring physicians and patients are notified.
"Other notification:
"VHA has notified NRC, Region III (NRC Project Manager, Cassandra Frasier)."
Notified R1DO(Summers), R3DO(Louden), and FSME(Mauer).
* * * UPDATE BY E. LEIDTHOLDT TO J. KOZAL ON 6/21/08 AT 1841 * * *
"This is an amendment to NRC Event Number 44219, reported on May 16, 2008, and is a notification per 10 CFR 35.3045 of additional possible medical events. VHA provided amendments on June 6 and 12, 2008. This amendment reflects the most current information.
"VHA notified the NRC Operations Center on May 16, 2008, of a possible medical event at the VA Medical Center, Philadelphia, Pennsylvania, involving a transperineal permanent seed implant prostate brachytherapy procedure of a patient. This patient procedure is now considered to be a medical event.
"VHA initiated a reactive inspection on May 28, 2008. As part of this reactive inspection, the medical center was requested to review additional prostate brachytherapy procedures.
"The medical center has identified 63 brachytherapy procedures that could be medical events because the D90 doses, determined from post-implant CT scans, were 80% or less than the prescribed doses. The procedures are still under evaluation and a final determination has not been made for 60 of these procedures. For three of these 63 procedures including the May 5, 2008, procedure, the D90 doses have been confirmed to be 80% or less than the prescribed doses.
"We note that the medical center routinely prescribes a dose of 160 gray instead of the more common 145 gray and that the number of possible events would be substantially less if the definition of a medical event were based upon the delivered dose instead of a percent of prescribed dose.
"Furthermore, the medical center determines D90 doses from post-implant CT scans performed the day after the procedures. Prostate swelling may cause the doses assessed from these scans to underestimate the delivered D90 doses.
"The permanent implant brachytherapy program is suspended and an external review is in progress.
"Effect on patients:
"VHA is continuing to evaluate these possible medical events. At this time, adverse effects to the patients are not expected. The external review will assess potential medical consequences.
"Patient notification:
"The three patients whose D90 doses were confirmed to be 80% or less than the prescribed doses and their referring physicians have been notified. If other patient procedures are determined to be medical events, the medical center will ensure that the referring physicians and patients are notified.
"Other notification:
"VHA will notify NRC, Region III (NRC Project Manager, Cassandra Frasier)."
Notified R1DO (Schmidt), R3DO (Kunowski), and FSME (Holonich)
* * * UPDATE PROVIDED BY THOMAS HUSTON TO JASON KOZAL AT 1758 ON 6/25/08 * * *
"This report is an update to Event Report #44219. As the result of an ongoing review, a medical event was discovered for a fourth patient on June 24, 2008. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of the event will be sent to NRC Region III."
Notified R1DO (Grey), R3DO (Burgess), and FSME EO (Camper).
* * * UPDATE PROVIDED BY THOMAS HUSTON TO JOHN KNOKE AT 1245 ON 07/02/08 * * *
"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional seven (7) patients on July 2, 2008. This brings the total number of medical events to eleven (11) under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these seven (7) additional medical events will be submitted to NRC Region III."
Notified R1DO (Bellamy), R3DO (Kozak), and FSME EO (Zelac).
* * * UPDATE FROM HUSTON TO CROUCH ON 07/08/08 AT 1319 EDT * * *
"As the result of an ongoing review, medical events were discovered for an additional seven (7) patients on July 7, 2008. This brings the total number of medical events to eighteen (18) under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these seven (7) additional medical events will be submitted to NRC Region III."
Notified R1DO (Burritt), R3DO (Duncan) and FSME EO (Burgess).
* * * UPDATE PROVIDED BY LYNN MCGUIRE TO JOHN KNOKE AT 1335 ON 07/09/08 * * *
A 15-day written report of one of the medical events was submitted to NRC Region III.
Notified R1DO (Burritt), R3DO (Duncan) and FSME EO (Burgess).
* * * UPDATE FROM THOMAS HUSTON TO JOE O'HARA AT 0943 ON 7/10/09 * * *
"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional two (2) patients on July 9, 2008. This brings the total number of medical events to twenty (20) under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these two (2) additional medical events will be submitted to NRC Region III.
"We have notified our NRC Project Manager, Cassandra Frazier (NRC Region III), of these additional events."
Notified R1DO(Burritt), R3DO(Duncan), and FSME EO(Burgess) |
| General Information or Other | Event Number: 44338 | Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: GEORGIA PACIFIC
Region: 3
City: NEENAH State: WI
County: WINNEBAGO
License #:
Agreement: Y
Docket:
NRC Notified By: DIANA SULAS
HQ OPS Officer: MARK ABRAMOVITZ | Notification Date: 07/07/2008
Notification Time: 12:33 [ET]
Event Date: 06/27/2008
Event Time: [CDT]
Last Update Date: 07/07/2008 | Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
| Person (Organization):
ERIC DUNCAN (R3)
CINDY FLANNERY (FSME)
|
| This material event contains a "Less than Cat 3" level of radioactive material. | Event Text AGREEMENT STATE REPORT - LOST STATIC ELIMINATOR
The state submitted this report via fax:
"On June 27, 2008 a representative of Georgia Pacific called to report the loss of an NRD static master ionizing unit Model 2u500 containing 500uCi of Po-210. A written report was received on July 7, 2008. These units have no serial number associated with them. They are used to control static on analytical balances. The balance with the missing static bar was put in a storage area for the lab. The probable disposition of the static bar is that it was either returned to the manufacturer or accidentally disposed of in the facility trash, which goes to the Winnebago County landfill. No exposure to individuals is probable. The general licensee conducted on extensive search of their facility, and instituted new procedures to prevent reoccurrence."
Wisconsin event: WI080007
THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. |
| Power Reactor | Event Number: 44342 | Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: MARTIN LICHTNER
HQ OPS Officer: HOWIE CROUCH | Notification Date: 07/10/2008
Notification Time: 16:18 [ET]
Event Date: 07/10/2008
Event Time: 15:38 [EDT]
Last Update Date: 07/10/2008 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
| Person (Organization):
ART BURRITT (R1)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | N | Y | 94 | Power Operation | 93 | Power Operation | | 2 | N | Y | 100 | Power Operation | 100 | Power Operation | Event Text LOSS OF EMERGENCY ASSESSMENT CAPABILITIES DUE TO PLANT COMPUTER FAILURE
"At 0738 hours on 07/10/08, reactor operators noticed that information on displays of the Plant Integrated Computer System were not periodically updating. Investigation by computer maintenance personnel was initiated. Reactor power was reduced 1 % to ensure compliance with license limits. As of 1538 hours, reliable operation of the computer was not restored.
"This computer system also performs the Safety Parameter Display System (SPDS) and Emergency Response Data System (ERDS) functions. Redundant, normal control room indications are still available to the operators.
"Since the Unit 1 SPDS and ERDS computer system were not reliable for greater than 8 hours, this is considered a Loss of Emergency Assessment Capability and therefore reportable under 10CFR50.72(b)(3)(xiii)."
Prior to this event, plant personnel were performing plant computer modifications. Compensatory measures are in place to provide emergency assessment data should an event occurs that requires it.
The licensee has notified the NRC Resident Inspector.
* * * UPDATE FROM JIM HUFFORD TO JOHN KNOKE AT2052 EDT ON 07/10/08 * * *
"This is a follow-up courtesy notification to EN# 44342. As of 2017 on 07/10/08, Unit 1 ERDS and PICSY were fully restored to normal operation. Unit 1 reactor power was returned to full power of 94.4% as of 2042 on 7/10/08."
The licensee has notified the NRC Resident Inspector. Notified R1DO (Art Burritt) | |