U.S. Nuclear Regulatory Commission Operations Center Event Reports For 07/20/2009 - 07/21/2009 ** EVENT NUMBERS ** | Hospital | Event Number: 45206 | Rep Org: NANTICOKE COOK MEMORIAL HOSPITAL Licensee: NANTICOKE COOK MEMORIAL HOSPITAL Region: 1 City: SEAFORD State: DE County: License #: 07-17618-01 Agreement: N Docket: NRC Notified By: MATTHEW RAJOTTE HQ OPS Officer: CHARLES TEAL | Notification Date: 07/15/2009 Notification Time: 12:54 [ET] Event Date: 03/15/2009 Event Time: [EDT] Last Update Date: 07/15/2009 | Emergency Class: NON EMERGENCY 10 CFR Section: 35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE | Person (Organization): HAROLD GRAY (R1DO) ANGELA MCINTOSH (FSME) | Event Text MEDICAL UNDEREXPOSURE DURING BRACHYTHERAPY "A prostate seed implant was performed on March 5th, 2009, using needles preloaded with I-125 seeds. After implanting a total of 61 seeds, 22 seeds were found and then retrieved from the bladder. The patient later returned for a pelvic CT for post implant dosimetry. This dosimetry revealed an under dosing of the prostate with a D90 dose less than 80% of the prescribed dose. The seed distribution error was caused by the position of the needles in respect to depth when the seeds were released. The patient received no ill effect, but requires further therapeutic radiation in order to complete the prescription. The patient is currently scheduled for a second seed implant to complete the therapy." 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. | Power Reactor | Event Number: 45212 | Facility: SAN ONOFRE Region: 4 State: CA Unit: [ ] [2] [3] RX Type: [1] W-3-LP,[2] CE,[3] CE NRC Notified By: GEOFF COOK HQ OPS Officer: HOWIE CROUCH | Notification Date: 07/20/2009 Notification Time: 19:13 [ET] Event Date: 07/20/2009 Event Time: 12:54 [PDT] Last Update Date: 07/20/2009 | Emergency Class: NON EMERGENCY 10 CFR Section: 26.719 - FITNESS FOR DUTY | Person (Organization): RICK DEESE (R4DO) | Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | 2 | N | Y | 99 | Power Operation | 99 | Power Operation | 3 | N | Y | 100 | Power Operation | 100 | Power Operation | Event Text FITNESS FOR DUTY REPORT - CONFIRMED POSITIVE FOR ALCOHOL A non-licensed supervisory employee had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access has been revoked. Contact the Headquarters Operations Officer for additional details. The licensee has notified the NRC Resident Inspector. | |