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Event Notification Report for July 21, 2009

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/20/2009 - 07/21/2009

** EVENT NUMBERS **


45206 45212

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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.

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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.

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Thursday, March 29, 2012