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Event Notification Report for March 24, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/23/2011 - 03/24/2011

** EVENT NUMBERS **


46683 46684 46692

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Agreement State Event Number: 46683
Rep Org: MINNESOTA DEPARTMENT OF HEALTH
Licensee: ABBOTT NORTHWESTERN HOSPITAL
Region: 3
City: MINNEAPOLIS State: MN
County:
License #: 1007-209-27
Agreement: Y
Docket:
NRC Notified By: BRYCE ARMSTRONG
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/18/2011
Notification Time: 16:13 [ET]
Event Date: 03/17/2011
Event Time: [CDT]
Last Update Date: 03/18/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KENNETH RIEMER (R3DO)
CHRISTEPHER MCKENNEY (FSME)

Event Text

AGREEMENT STATE REPORT - YTTRIUM-90 MICROSPSHERES ADMINISTERED AT 150% OF PRESCRIBED DOSE

"A medical event took place at Abbott-Northwestern Hospital involving a Yttrium-90 (Y-90) SIR microsphere therapy patient treated on 3/17/2011. It was discovered on 3/18/11, by the radiation oncologist covering the SIRS procedure from the day before, that the delivered amount of Y-90 SIRS wasn't 105% above the prescribed dose as intended, but actually 150% above the prescribed dose. She then brought this error to the attention of the lead medical physicist who was the attending medical physicist responsible for this treatment delivery, for further clarification. Upon investigation, it was deduced that the medical physicist had not read the patient's SIRS therapy (utilizing Y-90 radioactive isotope) written directive prescription correctly. A higher than intended dosage was administered to the patient (1.66 GBq). The correct dosage that was intended to be administered per the written directive was 1.11 GBq. After calculation was made after the incident it was determined that the intended dose to the liver was 30.72 Gy and the actual dose to the liver was 45.93 Gy.

"Contributing factors to the above error identified by the licensee are as follows:
"1. The amount of information presented in the SIRS written directive and the prescribed amount of isotope is hard to discern and is not set apart from all the other numbers presented.
"2. The prescribed activity is manually transferred to a secondary worksheet used in Nuclear Medicine to draw the dose to be administered and this secondary activity worksheet is not verified by a secondary party.

"The licensee stated that to prevent such an event from occurring in the future, the SIRS written directive document will be modified to display the prescribed activity more predominantly on the form as well as a space for initializing by a secondary party that the prescribed dose has been transferred/entered properly on the secondary activity worksheet that is used in Nuclear Medicine to draw the dose to be administered.

"The referring physicians as well as the patient have been or are in the process of being notified of this event.

"According to the licensee's Radiation Oncologist and Interventional Radiologist that were asked to consult, this higher dose would slightly increase the patient's risk of radiation-induced liver disease. The patient, as is standard for all SIRS (Y-90) patients, will receive liver function follow-up testing to track her status."


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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Agreement State Event Number: 46684
Rep Org: MINNESOTA DEPARTMENT OF HEALTH
Licensee: BOISE CASCADE PAPER CORPORATION
Region: 3
City: INTERNATIONAL FALLS State: MN
County:
License #: 5011-100-36
Agreement: Y
Docket:
NRC Notified By: BRANDON JURAN
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/18/2011
Notification Time: 17:34 [ET]
Event Date: 03/18/2011
Event Time: [CDT]
Last Update Date: 03/18/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KENNETH RIEMER (R3DO)
CHRISTEPHER MCKENNEY (FSME)

Event Text

AGREEMENT STATE REPORT - DENSITY GAUGE STUCK SHUTTER

"The licensee Radiation Safety Officer (RSO) was performing a routine shutter check on a density gauge (Berthold model LB7440); the shutter was difficult to turn so the RSO used pliers to move the shutter to the indicated closed position. The shutter did not close. The detector on the gauge was still reading the same as when the shutter was indicated open. The RSO contacted the manufacturer and is in the process of scheduling them to service the device. The RSO tagged the gauge with a do not operate tag warning people of the problem."

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Part 21 Event Number: 46692
Rep Org: AUTOMATIC VALVE
Licensee: AUTOMATIC VALVE
Region: 3
City: NOVI State: MI
County:
License #:
Agreement: N
Docket:
NRC Notified By: KEVIN ARMSTRONG
HQ OPS Officer: PETE SNYDER
Notification Date: 03/23/2011
Notification Time: 16:24 [ET]
Event Date: 03/22/2011
Event Time: [EDT]
Last Update Date: 03/23/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
JOHN ROGGE (R1DO)
DANIEL RICH (R2DO)
PART 21 GROUP (EMAI)

Event Text

VALVE PLUNGER GUIDE MALFUNCTION

"Initial Concern: Valve, serial number 73386, does not consistently return to the closed position."

"Nature of the Defect: A dent in the plunger guide may prevent the valve from changing state.

"Number and Location of Components:
"Model: U0204GBBR-AA Quantity: 32 Customer: EXELON LIMERICK,
"Model: U0204GBBR-DEEL Quantity: 30 Customer: ALABAMA POWER FARLEY
"Model: U0204GBBR-DE Quantity: 4 Customer: ALABAMA POWER FARLEY
"Model: U0204FBBR-DE Quantity: 8 Customer: RALPH A. HILLER
"Model: U0204GBBR-DEL Quantity: 4 Customer: DRESSER MASONEILAN
"Model: U0204GBBR-DEP Quantity: 3 Customer: DRESSER MASONEILAN

"Advice to Purchasers:

"Any of the valves identified above may be inspected by removing the coil and checking the plunger guide for any defects. A dent which will prevent plunger movement is noticeable without magnification. It typically occurs approximately 0.10 inches from the base of the valve. Any valves thought to contain defects will be rebuilt or replaced by Automatic Valve."

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