Event Notification Report for March 17, 2009
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/16/2009 - 03/17/2009
General Information or Other
Event Number: 44911
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: WESTERN PENNSYLVANIA HOSPITAL
Region: 1
City: PITTSBURGH State: PA
County:
License #: PA-0121
Agreement: Y
Docket:
NRC Notified By: JENNIFER KELLY
HQ OPS Officer: HOWIE CROUCH
Licensee: WESTERN PENNSYLVANIA HOSPITAL
Region: 1
City: PITTSBURGH State: PA
County:
License #: PA-0121
Agreement: Y
Docket:
NRC Notified By: JENNIFER KELLY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/17/2009
Notification Time: 09:05 [ET]
Event Date: 03/17/2009
Event Time: 00:00 [EDT]
Last Update Date: 03/17/2009
Notification Time: 09:05 [ET]
Event Date: 03/17/2009
Event Time: 00:00 [EDT]
Last Update Date: 03/17/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
ANNE DEFRANCISCO (R1)
ANGELA MCINTOSH (FSME)
ANNE DEFRANCISCO (R1)
ANGELA MCINTOSH (FSME)
PENNSYLVANIA AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was received from the State of Pennsylvania via email:
"A female patient was to receive HDR twice a day for a total of 10 treatments with an expected dose of 34Gy via mammosite treatment. A dummy wire was inserted into the balloon to check and measure the tube length for dosage calculations. A CT scan was performed daily to verify the position of the treatment site. Treatment calculations were done, reviewed, approved, and treatment began Monday, February 23, 2009.
"[On] Friday, February 27, 2009, a different therapy physicist was checking the patients charts and thought that there may have been an error.
"[On] Monday, March 2, 2009, the original physicist checked the findings of the different therapy physicist and discovered that there had been an error in the placement of the source during the treatment. The source was not fully inserted into the balloon, but was 3cm from where it should have been, thereby resulting not only in a large difference in the tumor dose received (approx. 30% of intended) but also in a severe dosage to non-intended areas of the patient.
"The physicist, RSO and two licensee's radiation oncologist reviewed the situation once it was discovered. The patient is being followed for any sequelae (pathological conditions) to the event. It was reported that erythema (dilated capillaries) is developing consequential to the event. Follow ups are expected to occur weekly. The oncologist has discussed the event with the patient."
PA Case # PA090011
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.
The following information was received from the State of Pennsylvania via email:
"A female patient was to receive HDR twice a day for a total of 10 treatments with an expected dose of 34Gy via mammosite treatment. A dummy wire was inserted into the balloon to check and measure the tube length for dosage calculations. A CT scan was performed daily to verify the position of the treatment site. Treatment calculations were done, reviewed, approved, and treatment began Monday, February 23, 2009.
"[On] Friday, February 27, 2009, a different therapy physicist was checking the patients charts and thought that there may have been an error.
"[On] Monday, March 2, 2009, the original physicist checked the findings of the different therapy physicist and discovered that there had been an error in the placement of the source during the treatment. The source was not fully inserted into the balloon, but was 3cm from where it should have been, thereby resulting not only in a large difference in the tumor dose received (approx. 30% of intended) but also in a severe dosage to non-intended areas of the patient.
"The physicist, RSO and two licensee's radiation oncologist reviewed the situation once it was discovered. The patient is being followed for any sequelae (pathological conditions) to the event. It was reported that erythema (dilated capillaries) is developing consequential to the event. Follow ups are expected to occur weekly. The oncologist has discussed the event with the patient."
PA Case # PA090011
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.
General Information or Other
Event Number: 44912
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: UNION CARBIDE CORPORATION
Region: 4
City: SEADRIFT State: TX
County:
License #: 00051
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: UNION CARBIDE CORPORATION
Region: 4
City: SEADRIFT State: TX
County:
License #: 00051
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/18/2009
Notification Time: 09:44 [ET]
Event Date: 03/17/2009
Event Time: 00:00 [CDT]
Last Update Date: 05/05/2009
Notification Time: 09:44 [ET]
Event Date: 03/17/2009
Event Time: 00:00 [CDT]
Last Update Date: 05/05/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MICHAEL HAY (R4)
ANGELA MCINTOSH (FSME)
MICHAEL HAY (R4)
ANGELA MCINTOSH (FSME)
AGREEMENT STATE REPORT - PROCESS GAUGE SHUTTER HANDLE BROKE
"On the afternoon of 3/17/09, while closing the shutter of a Ohmart/Vega SH-F1 level detection gauge, the handle separated from the shutter closure device. The gauge contains a 10 milliCurie Cesium (Cs) - 137 source serial # 5747 GK. The license can not confirm the exact position of the shutter, but they are sure that it is not closed yet. Lubricants have been used on the shutter mechanism to aid in its operation. The licensee will continue their attempts to close the shutter on 3/18/09. If unable to close, they will request assistance from the manufacturer. Additional information will be provided as it is received."
Texas Event: I-8620
* * * UPDATE FROM ART TUCKER TO HOWIE CROUCH VIA EMAIL @1745 ON 3/18/09 * * *
"The Radiation Safety Officer notified the [State of Texas] that the gauge had not been fully closed yet, but area dose rates were normal therefore the gauge does not create additional risk of exposure to their workers."
Notified R4DO (Hay) and FSME EO (Camper).
* * * UPDATE FROM ART TUCKER TO JOE O'HARA VIA EMAIL AT 1021 ON 5/5/09 * * *
"The licensee reported [to the State of Texas] that on April 28, 2009, a technician from the manufacturer installed a shield over the source and removed the gauge from the vessel. The gauge has been placed in a radioactive material storage area until it can be packaged and returned to the manufacturer."
Notified R4DO (Pick) and FSME EO (McIntosh).
"On the afternoon of 3/17/09, while closing the shutter of a Ohmart/Vega SH-F1 level detection gauge, the handle separated from the shutter closure device. The gauge contains a 10 milliCurie Cesium (Cs) - 137 source serial # 5747 GK. The license can not confirm the exact position of the shutter, but they are sure that it is not closed yet. Lubricants have been used on the shutter mechanism to aid in its operation. The licensee will continue their attempts to close the shutter on 3/18/09. If unable to close, they will request assistance from the manufacturer. Additional information will be provided as it is received."
Texas Event: I-8620
* * * UPDATE FROM ART TUCKER TO HOWIE CROUCH VIA EMAIL @1745 ON 3/18/09 * * *
"The Radiation Safety Officer notified the [State of Texas] that the gauge had not been fully closed yet, but area dose rates were normal therefore the gauge does not create additional risk of exposure to their workers."
Notified R4DO (Hay) and FSME EO (Camper).
* * * UPDATE FROM ART TUCKER TO JOE O'HARA VIA EMAIL AT 1021 ON 5/5/09 * * *
"The licensee reported [to the State of Texas] that on April 28, 2009, a technician from the manufacturer installed a shield over the source and removed the gauge from the vessel. The gauge has been placed in a radioactive material storage area until it can be packaged and returned to the manufacturer."
Notified R4DO (Pick) and FSME EO (McIntosh).