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Event Notification Report for November 3, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/02/2011 - 11/03/2011

** EVENT NUMBERS **


47384 47385 47403

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Hospital Event Number: 47384
Rep Org: JEPPESEN RADIATION ONCOLOGY
Licensee: BAY REGIONAL MEDICAL CENTER
Region: 3
City: BAY CITY State: MI
County:
License #: 21-18585-01
Agreement: N
Docket:
NRC Notified By: DENNIS KEHOE
HQ OPS Officer: JOE O'HARA
Notification Date: 10/28/2011
Notification Time: 15:26 [ET]
Event Date: 01/11/2011
Event Time: 07:00 [EDT]
Last Update Date: 11/01/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
PATTY PELKE (R3DO)
LYDIA CHANG (FSME)

Event Text

MEDICAL EVENT - MISADMINISTRATION OF PROSTATE CANCER SEEDS

During a recent inspection, an NRC inspector noted two cases which occurred on 8/23/11 and 1/11/11, respectively in which two separate patients were under dosed by greater than 20% during prostate cancer treatment using Iodine 125 seeds. The underdose was determined during post operative treatments. The same physician administered the procedure in both cases. The licensee has informed the prescribing physician, and is investigating the cause of the events. There is no long term permanent functional damage suspected to any organ in either case.

The licensee discussed the issue with NRC Region 3 (Gattone).

* * * UPDATE FROM DENNIS KEHOE TO VINCE KLCO ON 11/01/11 AT 1841 EDT * * *

After the licensee reviewed 3 years of medical reports, fourteen patents were found to have been under-dosed greater than 20% of the prescribed dose. Specific under-dose dates were: 4/10/08; 4/21/08; 4/25/08; 9/15/08; 10/17/08; 11/03/08; 2/17/09; 8/27/09; 1/05/10; 1/14/10; 5/25/10; 10/12/10; 5/03/11 and 5/19/11.

The licensee discussed the issue with NRC Region 3 (Gattone).

Notified the R3DO (Valos) and the FSME EO (Camper).

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: 47385
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: LANKENAU HOSPITAL
Region: 1
City: WYNNEWOOD State: PA
County:
License #: PA-0107
Agreement: Y
Docket:
NRC Notified By: JOE MELNIC
HQ OPS Officer: JOHN KNOKE
Notification Date: 10/28/2011
Notification Time: 16:02 [ET]
Event Date: 10/06/2011
Event Time: 00:00 [EDT]
Last Update Date: 10/28/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANNE DeFRANCISCO (R1DO)
LYDIA CHANG (FSME)

Event Text

AGREEMENT STATE REPORT - FETUS EXPOSED TO RADIATION DURING THYROID THERAPY TREATMENT

The following was received from the state via facsimile:

"The patient took a pregnancy test on October 5, 2011 and the results were negative. The patient was then treated with 73.7mCi of I-131 thyroid therapy treatment on October 6, 2011. The patient discovered she was pregnant and contacted the licensee on October 26, 2011. The estimated dose to the fetus is 17.4 Rads. It has been determined that the fetus was 10 days old when the therapy was given to the patient.

"The licensee will be submitting a written report within 15 days. The Department plans to do a reactive inspection to review licensee's procedures and response to this ME."

Event Report ID No. PA110031

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Power Reactor Event Number: 47403
Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: DAVID GIBSON
HQ OPS Officer: VINCE KLCO
Notification Date: 11/02/2011
Notification Time: 20:41 [ET]
Event Date: 11/02/2011
Event Time: 14:30 [EDT]
Last Update Date: 11/02/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
NEIL PERRY (R1DO)

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

Event Text

UNANALYZED CONDITION CAUSED BY NON-CONFORMING FIRE BARRIERS

"Ongoing field inspections as a result of Industry Operating Experience have identified certain fire barriers that are not in conformance with required tested configurations. Specifically, some of the flexible conduit that penetrates these barriers has a coating that does not exhibit flame retardant characteristics and therefore does not meet the requirements for fire barriers at Beaver Valley Power Station, Unit 1.

"In the event of a postulated fire, this non-conformance has the potential to affect fire barriers separating the two independent trains required for post fire Safe Shutdown equipment. This issue is being reported per 10CFR 50.72(b)(3)(ii)(B).

"Compensatory actions have been established in accordance with the approved Fire Protection Program.

"The NRC Resident Inspector has been notified."

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Thursday, March 29, 2012