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Event Notification Report for March 31, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/30/2010 - 03/31/2010

** EVENT NUMBERS **


45788 45794

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General Information or Other Event Number: 45788
Rep Org: MINNESOTA DEPARTMENT OF HEALTH
Licensee: MAYO CLINIC
Region: 3
City: ROCHESTER State: MN
County: OLMSTED
License #: 1047-205-55
Agreement: Y
Docket:
NRC Notified By: GEORGE JOHNS
HQ OPS Officer: VINCE KLCO
Notification Date: 03/25/2010
Notification Time: 15:27 [ET]
Event Date: 03/23/2010
Event Time: [CDT]
Last Update Date: 03/25/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
LAURA KOZAK (R3DO)
ANDREA KOCK (FSME)

Event Text

AGREEMENT STATE REPORT - IMPROPER DOSAGE GIVEN DURING MEDICAL TREATMENT

The following information was received by e-mail:

"On March 25, 2010, Mayo Clinic notified the Minnesota Department of Health of an HDR [High Dose Rate After Loader] medical event. The patient was prescribed four fractions of 4 Gy for a biliary HDR treatment. The catheter had been placed and imaged. A dummy source was pushed into the catheter until it met resistance that was assumed to be the end of the catheter. In fact, the resistance was a tight bend approximately 17 centimeters (6.69 inches) short of the end.

"The distance that was thought to be the end of the catheter was incorrectly used for the treatment distance and the patient was subsequently treated. Prior to treatment the following day, a dummy source was again inserted. That source extended beyond the programmed distance. An x-ray revealed that the end of the catheter was beyond the initial treatment location.

"For the first two fractions, the HDR source was 17 cm from its intended treatment location. This resulted in the tumor receiving only 30 percent of the intended fractional dose and resulted in the duodenum (where the HDR source was located) receiving more than 50 rem and more than 50 percent of planned."

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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General Information or Other Event Number: 45794
Rep Org: NE DIV OF RADIOACTIVE MATERIALS
Licensee: OMAHA PUBLIC POWER DISTRICT
Region: 4
City: OMAHA State: NE
County:
License #: 01-39-04
Agreement: Y
Docket:
NRC Notified By: JIM DeFRAIN
HQ OPS Officer: PETE SNYDER
Notification Date: 03/26/2010
Notification Time: 13:36 [ET]
Event Date: 03/25/2010
Event Time: 11:35 [CDT]
Last Update Date: 03/26/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

PROCESS GAUGE SHUTTER MALFUNCTION

The following information was received from the State of Nebraska via facsimile:

"The licensee uses fixed industrial gauges for measuring densities in fly ash hoppers at the station's precipitator building. The industrial gauges contain a Cesium 137 sealed source. The Cesium 137 sources were originally installed in 1975 and at the time contained 50 millicuries per source.

"The sources were manufactured and installed by Kay Ray Inc.

"The gauges are Model No. 7700-50.

"The licensee was attempting to close the shutter on the fixed gauge prior to performing maintenance. One of the external closure cables was found to be slightly bound up and only partially closed the 'internal' source shutter. The cable closure was reopened, which reopened the source shutter up at the sealed source. Closure was tried again. This time the cable, which connects the handle at the floor to the sealed source shutter mechanism 20 feet above, bent instead of sliding the cable to the closed position.

"This 'event' happened at 11:35 am and was reported to the station's Shift Supervisor who in turn contacted the plant electricians to make repairs so the precipitator 'tag-out' could continue. By 11:45 am the cable had been closed and the lab contacted to perform a survey to verify the source shutter was now in the closed position. No personnel were exposed to radiation during this event."

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