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Event Notification Report for December 28, 2010

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
12/27/2010 - 12/28/2010

** EVENT NUMBERS **


46500 46501 46513

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General Information Event Number: 46500
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: ST ELIZABETH HOSPITAL
Region: 3
City: APPLETON State: WI
County:
License #: 087-1284-01
Agreement: Y
Docket:
NRC Notified By: MEGAN SHOBER
HQ OPS Officer: JOHN KNOKE
Notification Date: 12/21/2010
Notification Time: 12:30 [ET]
Event Date: 11/30/2010
Event Time: [CST]
Last Update Date: 12/21/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ERIC DUNCAN (R3DO)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT- PROSTATE BRACHYTHERAPY TREATMENT UNDERDOSES

This information was emailed by the state as follows:

"In July 2010, the Wisconsin Department of Health Services (DHS) sent out an Information Notice to all licensees who perform prostate brachytherapy and asked them to perform a retrospective review of all prostate brachytherapy cases to determine whether any medical events had occurred. During a recent routine inspection, DHS determined that in response to the Information Notice, this licensee was reviewing medical records of several patients who may have received doses during prostate brachytherapy that were less than intended. On November 30, 2010, the licensee's Radiation Safety Officer reported the preliminary identification of one medical event. On December 20, 2010, the licensee's 15-day written report included information on this event, plus an additional two medical events. The doses delivered are D90 values based on CT scans performed thirty days post-surgery.

Treatment Date Isotope Prescription Dose Delivered Percentage
6/17/2008 Pd-103 125 Gy to prostate 97.4 Gy to prostate 77.9%
8/24/2009 I-125 145 Gy to prostate 107.9 Gy to prostate 74.4%
9/02/2009 I-125 145 Gy t0 prostate 93.05 Gy to prostate 64.2%


"The licensee is complying with the reporting criteria in DHS 157.72(1)(e) concerning notifications to the patients and referring physicians. The licensee stated that the events occurred due to clinical limitations of the interstitial prostate brachytherapy implant technique. The licensee made process improvements (i.e. planning to D90 of 115% of the prescribed dose) which have resulted in unproved dosimetric coverage. DHS inspectors performed a reactive inspection and will follow up on the next inspection."

Event Report ID No.: WI100018


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 Event Number: 46501
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: MERCY MEDICAL CENTER
Region: 3
City: OSHKOSH State: WI
County:
License #: 139-1177-01
Agreement: Y
Docket:
NRC Notified By: MEGAN SHOBER
HQ OPS Officer: JOHN KNOKE
Notification Date: 12/21/2010
Notification Time: 12:30 [ET]
Event Date: 08/12/2008
Event Time: [CST]
Last Update Date: 12/21/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ERIC DUNCAN (R3DO)
MICHELE BURGESS (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT- PROSTATE BRACHYTHERAPY TREATMENT UNDERDOSE

This information was emailed by the state as follows:

"In July 2010, the Wisconsin Department of Health Services (DHS) sent out an Information Notice to all licensees who perform prostate brachytherapy and asked them to perform a retrospective review of all prostate brachytherapy cases to determine whether any medical events had occurred. On December 20, 2010, the licensee's Radiation Safety Officer notified DHS that on August 12, 2008 a patient received only 75.4 % of the prescribed dose during prostate brachytherapy using I-125 seeds. The patient was prescribed 145 Gy to the prostate, and based on a CT scan performed thirty days post-surgery, the licensee determined that the treatment delivered only 109.3 Gy to the prostate.

"The authorized user who treated this patient is no longer at the licensee's facility. The licensee is complying with the reporting criteria in DHS 157.72(1)(e) concerning notifications to the patient and referring physician. The licensee has already made process improvements (i.e. planning to higher D90 values) which have resulted in improved dosimetric coverage. DHS inspectors will follow up on the next routine inspection."

Event Report ID # WI100019

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: 46513
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: GREG MILLER
HQ OPS Officer: JOE O'HARA
Notification Date: 12/27/2010
Notification Time: 16:18 [ET]
Event Date: 12/27/2010
Event Time: 15:37 [EST]
Last Update Date: 12/27/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
JULIO LARA (R3DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 75 Power Operation 75 Power Operation

Event Text

OFFSITE NOTIFICATIONS - EXCEEDED DISCHARGE PERMIT

"On December 27, 2010, at 1537, a report was made to the Michigan Department of Natural Resources and Environment for exceeding the National Pollutant Discharge Elimination System (NPDES) permit limits to outfall 011A. The limits were exceeded due to the General Service Water (GSW) traveling screens being in continuous operation and the back wash being aligned to outfall 011A which resulted in exceeding the maximum discharge limit of 1.8 million gallons per calendar day as a result of a fish intrusion event occurring at the GSW intake. The GSW traveling screens have been in continuous operation since 2100 on December 25 and the daily discharge limit was reached at 1700 on December 26. The condition was necessary to maintain safe and reliable operations of the plant in response to the fish intrusion. The GSW traveling screens are being continuously monitored in order to limit unnecessary discharge into outfall 011A and restore full compliance with the NPDES permit as conditions improve. This report is being made in accordance with 10CFR50.72(b)(2)(xi) 'Any event or situation. Related to the health and safety of the public or onsite personnel, or protection of the environment, for which a news release is planned or notification to other government agencies has been or will be made.' "

The NRC Resident Inspector has been notified.

Page Last Reviewed/Updated Thursday, March 29, 2012
Thursday, March 29, 2012