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Event Notification Report for July 8, 2011

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Event Reports For
07/07/2011 - 07/08/2011

** EVENT NUMBERS **


47005 47008 47011 47025 47032 47033

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Agreement State Event Number: 47005
Rep Org: NV DIV OF RAD HEALTH
Licensee: UNIVERSITY MEDICAL CENTER
Region: 4
City: LAS VEGAS State: NV
County:
License #: 03-12-0034-01
Agreement: Y
Docket:
NRC Notified By: SNEHA RAVIKUMAR
HQ OPS Officer: JOE O'HARA
Notification Date: 07/01/2011
Notification Time: 12:57 [ET]
Event Date: 12/09/2009
Event Time: [PDT]
Last Update Date: 07/01/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES DRAKE (R4DO)
CHRIS EINBERG (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT - RADIOPHARAMACEUTICAL ADMINISTERED TO WRONG PATIENT

The following information was received via e-mail:

"On Wednesday, December 9, 2009, an 8 mCi dose of Tc-99m Sestamibi was administered via IV injection to an incorrect patient. The patient receiving the misinjection did not have a written order for the procedure in their medical chart. The event was reported to the RCP (Radiation Control Program) by telephone on Thursday December 10, 2009, as required in NRC 35.3045, 'Report and Notification of a Medical Event.'

"The misinjection was a result of the technologist failing to follow established written policy and procedure of verifying the patient I.D. with three identifiers: Name (patient spelling last name), DOB (verbalized by patient) and UMC Account Number and not using an interpreter as directed by policy. This procedure of patient identification has been established as a barrier to prevent such a situation from occurring. Failure to follow procedure is in direct violation of hospital policy and resulted in disciplinary action.

"The patient was immediately notified of the event. No adverse effect of the injection has been foreseen considering the activity of the radiopharmaceutical administered. The physician of the patient was also notified of the misinjection by telephone.

"The RSO has been notified of the misinjection and the details of the incident have been entered into the minutes of the radiation safety committee meeting for this quarter on December 10, 2009.

"This event is closed.

"Item Number: NV090001."

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: 47008
Rep Org: NEW YORK STATE DEPT. OF HEALTH
Licensee: NY HOSPITAL
Region: 1
City: NEW YORK State: NY
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT SNYDER
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/01/2011
Notification Time: 11:19 [ET]
Event Date: 10/25/2007
Event Time: [EDT]
Last Update Date: 07/01/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAKE WELLING (R1DO)
DEBORAH JACKSON (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION DURING GAMMA KNIFE THERAPY

The following report was received via fax:

"On 10/25/2007, [the New York State Department of Health] received a call from a radiation oncology manager to report a therapy misadministration involving a gamma knife due to a machine malfunction, couch failure. The physicist and the neurosurgeon had to go in and manually pull the couch out. The physicist's badge was read on an emergency basis and showed DDE of 1 mRem and SDE of 2 mRem. The neurosurgeon did not have his badge on when he went in. The facility has treated about 125 patients in 4 years with the gamma knife unit, according to field notes from the inspection done in February 2007 and is close to the 5 year service requirement. The facility had planned to treat 10 lesions in the brain but stopped after 3 lesions were treated due to couch failure. The rest of the lesions were not treated with radiation. The patient had already received whole brain irradiation and received additional chemotherapy after the gamma knife procedure.

"Service performed: couch repaired. Policy & Procedure regarding film badge use reviewed during next routine inspection. This event is closed."

New York Event: NY-11-15
New York Incident: 570

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: 47011
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: HIGHLANDS REGIONAL MEDICAL CENTER
Region: 1
City: PRESTONBURG State: KY
County:
License #: 202-102-26
Agreement: Y
Docket:
NRC Notified By: MICHELE GREENWELL
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/01/2011
Notification Time: 14:13 [ET]
Event Date: 02/18/2008
Event Time: [CDT]
Last Update Date: 07/01/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BLAKE WELLING (R1DO)
DEBORAH JACKSON (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION DURING PROSTATE THERAPY

The state found three cases of prostate seed (Pd-103) medical misadministration during an inspection on 1/14/2011. These cases are related to one doctor.

2/18/2008: 100 Gy prescribed, 70.24 Gy administered
4/8/2008: 125 Gy prescribed, 71.6 Gy administered
3/17/2009: 100 Gy prescribed, 160.8 Gy administered

The physician was notified of the misadministration however the patients were not notified.

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: 47025
Facility: COOK
Region: 3 State: MI
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DAN KURTH
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/06/2011
Notification Time: 03:14 [ET]
Event Date: 07/06/2011
Event Time: 04:00 [EDT]
Last Update Date: 07/07/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DAVID HILLS (R3DO)

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

Event Text

UNAVAILABILITY OF TSC VENTILATION SYSTEM DUE TO SCHEDULED MAINTENANCE

"At 0400 EDT on Wednesday, July 6, 2011, the Cook Nuclear Plant (CNP) Technical Support Center (TSC) air conditioning and charcoal filtration systems will be removed from service for scheduled maintenance.

"Under certain accident conditions the TSC may become unavailable due to the inability of the air conditioning and charcoal filtration systems to maintain a habitable atmosphere. Compensatory measures exist to relocate TSC personnel to the unaffected unit's control room if necessary.

"TSC ventilation system maintenance is scheduled to be completed by 1600 EDT on Wednesday, July 6, 2011.

"The licensee has notified the NRC Resident Inspector.

"This notification is being made in accordance with 10 CFR 50.72 (b)(3)(xiii) due to the loss of an emergency response facility."

* * * UPDATE FROM DEAN BRUCK TO PETE SNYDER ON 7/7/11 AT 1056 EDT * * *

"The TSC ventilation system maintenance was completed satisfactorily and the system restored to service at 1500 EDT on 7/6/11."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 47032
Facility: VOGTLE
Region: 2 State: GA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: BILL DUNN
HQ OPS Officer: STEVE SANDIN
Notification Date: 07/07/2011
Notification Time: 11:11 [ET]
Event Date: 07/07/2011
Event Time: 09:00 [EDT]
Last Update Date: 07/07/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
BRIAN BONSER (R2DO)

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

Event Text

EMERGENCY SIREN OUTAGE

"At 0900 EDT, the Shift Manager was notified that all off site notification sirens were discovered inoperable during the daily maintenance checks due to a loss of power supply. Upon discovery by the technicians of the loss of power supply, the backup power supply was energized and all sirens were tested and returned to operable status.

"The time of power loss is unknown at this time and the reason for the failure of the transfer to the backup power supply appears to be a bad solder joint.

"The backup power supply has been verified SAT."

The sirens were last tested satisfactorily on Tuesday, 7/5/11.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 47033
Facility: FORT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: (1) CE
NRC Notified By: ROBERT KROS
HQ OPS Officer: VINCE KLCO
Notification Date: 07/07/2011
Notification Time: 14:50 [ET]
Event Date: 07/07/2011
Event Time: 13:40 [CDT]
Last Update Date: 07/07/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
BOB HAGAR (R4DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

LOSS OF POWER TO 10 EMERGENCY SIRENS

"Power has been removed from 10 (out of 101) sirens due to flooding conditions. [Three] out of 5 sirens in Pottawattamie county, 4 of 18 in Harrison county and 3 of 78 in Washington county. There are compensatory measures in place to ensure notification to any members of the public that may still be in these areas. The station is also suspending testing and reporting (performance indicator) data for these sirens in accordance with NEI 99-02. All of these sirens serve areas for which there are no residents requiring evacuation. This is being reported per 10CFR50.72(b)(3)(xiii)) for 'Any event that results in a major loss of emergency assessment capability, offsite response capability, or communications capability'."

The licensee notified the States of Nebraska and Iowa, the Counties of Harrison, Washington and Pottawattamie and the NRC Resident Inspector of this report.

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Thursday, March 29, 2012