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Event Notification Report for June 28, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/27/2011 - 06/28/2011

** EVENT NUMBERS **


46975 46978

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Agreement State Event Number: 46975
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: ST. MARY'S HOSPITAL - RHINELANDER
Region: 3
City: RHINELANDER State: WI
County:
License #: 085-1296-01
Agreement: Y
Docket:
NRC Notified By: CHERYL K. ROGERS
HQ OPS Officer: STEVE SANDIN
Notification Date: 06/21/2011
Notification Time: 12:37 [ET]
Event Date: 06/15/2011
Event Time: [CDT]
Last Update Date: 06/21/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
KENNETH RIEMER (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - TWO I-125 INCIDENTS INVOLVING TOTAL DOSE LESS THAN PRESCRIBED DOSE

The State of Wisconsin sent the following report via email:

"On June 15, 2011, the licensee's Radiation Safety Officer reported the identification of two medical events that were discovered, involving permanent implants of I-125 for prostate brachytherapy where the total dose delivered differs from the prescribed dose by 20% or more. During a routine inspection conducted on March 8, 2011, DHS (Department of Health Services) inspectors determined that the licensee was not reviewing prostate brachytherapy cases against the medical event criteria and identified numerous potential medical events. A Confirmatory Action Letter was sent on April 6, 2011 which required the licensee to have all of their manual brachytherapy prostate implants reviewed by an outside radiation oncologist. Upon completion of the external review of the licensee's manual brachytherapy program for prostate implants, the licensee identified the following underdoses to the prostate (using D90<80% and D90>120% as medical event criteria):

"December 12, 2005: Prescribed dose 108 Gy. Prostate D90 was 67.16%.
"July 26, 2007: Prescribed dose 144 Gy. Prostate D90 was 74.09%.

"The licensee RSO stated that they will not be notifying the patients involved. DHS will send a special inspection team following the receipt of the licensee's 15 day written report."

Wisconsin Event Report ID No.: WI10007

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: 46978
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: MEADWESTVACO VIRGINIA CORPORATION
Region: 1
City: COVINGTON State: VA
County:
License #: 580-375-1
Agreement: Y
Docket:
NRC Notified By: CHARLES COLEMAN
HQ OPS Officer: CHARLES TEAL
Notification Date: 06/23/2011
Notification Time: 14:34 [ET]
Event Date: 06/22/2011
Event Time: [EDT]
Last Update Date: 06/23/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
JIM LUEHMAN (FSME)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTER ON FIXED GAUGE

The following was received via fax:

"During a routine test on June 22, 2011, the licensee determined the shutter on a fixed gauge failed to completely close. The gauge is used to monitor levels in a digester tank and was identified as a Berthold Technologies Model LB 7444, serial number 903-2-92. It contains a 7.8 milliCurie Cobalt-60 source. The licensee has contacted Berthold to repair or replace the gauge."

Virginia Report #: VA-11-0002

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Thursday, March 29, 2012