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Event Notification Report for November 2, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/01/2010 - 11/02/2010

** EVENT NUMBERS **


46366 46371 46381 46385

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Hospital Event Number: 46366
Rep Org: COMMUNITY HOSPITAL
Licensee: COMMUNITY HOSPITAL
Region: 3
City: MUNSTER State: IN
County:
License #: 13-15882-01
Agreement: N
Docket:
NRC Notified By: MIREL PALAMARU
HQ OPS Officer: STEVE SANDIN
Notification Date: 10/27/2010
Notification Time: 15:45 [ET]
Event Date: 10/26/2010
Event Time: [EDT]
Last Update Date: 10/27/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
MICHELE BURGESS (FSME)

Event Text

TWO MEDICAL EVENTS INVOLVING RECEIVED DOSE LESS THAN PRESCRIBED DOSE

During an on-site NRC Inspection on 10/26/10, two (2) medical events were identified both involving a delivered dose less than the prescribed dose following implant of Palladium-103 seed for prostate therapy. Specific details as follows:

First Medical Event

Preplanning date: 08/26/09
Post planning date: 09/03/09
D-90 (dose received by 90% of the prostate volume): 72%
Underdose: 28%
Prescribed: Palladium-103, 156U consisting of 65 seeds, 2.4U/seed

Second Medical Event

Preplanning date: 12/08/09
Post planning date: 12/29/09
D-90 (dose received by 90% of the prostate volume): 64%
Underdose: 36%
Prescribed: Palladium-103, 173U consisting of 74 seeds, 2.4U/seed

Both underdoses are attributed to prostate swelling. The physician reviewing the results concluded that there was no adverse impact on either patient. The licensee will continue reviewing medical records to identify any additional occurrences of this nature.

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: 46371
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH
Licensee: PLASTI-PAINT, INC
Region: 3
City: DE WITT State: IA
County:
License #: 3272123SEM
Agreement: Y
Docket:
NRC Notified By: NANCY FARRINGTON
HQ OPS Officer: JOHN KNOKE
Notification Date: 10/28/2010
Notification Time: 12:06 [ET]
Event Date: 10/28/2010
Event Time: [CDT]
Last Update Date: 10/28/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD SKOKOWSKI (R3DO)
MICHELE BURGESS (FSME)
ILTAB via e-mail ()

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - IOWA LICENSEE LOST A STATIC ELIMINATOR

The Iowa Department of Public Health provided the following report via e-mail:

"The Iowa Department of Public Health was informed on 10/28/10 that Registrant number 3272-1-0403, Plasti-Paint, lost a Static Eliminator (SN: A2GV069)."

The radionuclide is a 0.01 Ci sealed source of Po-210. The Static Eliminator was manufactured by NRD, Inc, Model number: P-2021-8201. The cause of this loss was human error.


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. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Hospital Event Number: 46381
Rep Org: COMMUNITY HEALTHCARE SYSTEM
Licensee: COMMUNITY HOSPITAL
Region: 3
City: MUNSTER State: IN
County:
License #:
Agreement: N
Docket:
NRC Notified By: MIREL PALAMARU
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/01/2010
Notification Time: 16:25 [ET]
Event Date: 05/28/2008
Event Time: [EDT]
Last Update Date: 11/01/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JOHN GIESSNER (R3DO)
CHRISTEPHER MCKENNEY (FSME)

Event Text

TWO MEDICAL EVENTS INVOLVING RECEIVED DOSE LESS THAN PRESCRIBED DOSE

During an on-site NRC Inspection two (2) medical events were identified both involving a delivered dose less than the prescribed dose following implant of Palladium-103 seed for prostate therapy. Specific details as follows:

First Medical Event

Preplanning date: 5/18/08
Post planning date: 5/18/08
Dose received by prostate volume: 44%
Underdose: 56%
Prescribed: Palladium-103, 140.42U consisting of 59 seeds, 2.38U/seed

Second Medical Event

Preplanning date: 7/8/08
Post planning date: 7/8/08
Dose received by prostate volume: 44%
Underdose: 56%
Prescribed: Palladium-103, 196.80U consisting of 82 seeds, 2.38U/seed

Both underdoses are attributed to prostate swelling. The physician reviewing the results concluded that there was no adverse impact on either patient. The licensee will continue reviewing medical records to identify any additional occurrences of this nature.

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: 46385
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [ ] [2] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: ANTHONY PETRELLI
HQ OPS Officer: VINCE KLCO
Notification Date: 11/01/2010
Notification Time: 23:30 [ET]
Event Date: 11/01/2010
Event Time: 20:04 [EDT]
Last Update Date: 11/01/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
JOHN WHITE (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 100 Power Operation

Event Text

OFFSITE NOTIFICATION DUE TO OIL SPILL

"During the performance of rounds an operator found a leak on the traveling water screens. The traveling water screens are part of the Service Water System. The travelling screen drive chain oil reservoir was found empty. It is estimated that approximately 5 gallons of oil entered the Service Water System forebay. The oil residue has been cleaned up. The environmental impact will be assessed following further investigation.

"Notifications have been made to NYSDEC [New York State Department of Environmental Conservation] and National Response Center."

NYS (New York State) spill #: 1008090

National Response Center spill #: 958672.

The licensee will notify the NRC Resident Inspector.

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Thursday, March 29, 2012