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Event Notification Report for March 6, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/05/2013 - 03/06/2013

** EVENT NUMBERS **


48780 48784 48807

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Agreement State Event Number: 48780
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH
Licensee: MERCY MEDICAL CENTER
Region: 3
City: CEDAR RAPIDS State: IA
County:
License #: 0017157M1
Agreement: Y
Docket:
NRC Notified By: RANDY DAHLIN
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 02/25/2013
Notification Time: 10:28 [ET]
Event Date: 01/17/2013
Event Time: [CST]
Last Update Date: 03/04/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMNES CAMERON (R3DO)
FSME RESOURCES ()

Event Text

AGREEMENT STATE REPORT - PROSTATE SEED IMPLANT UNDERDOSE

A prostate patient received a medical order for 74 I-125 seeds (144 Gray). The implantation was performed on January 17, 2013 with three seeds being recovered in the operating room and the patient passed two seeds. The post surgery CT scan was performed on February 20, 2013 and the post plan was performed on February 25, 2013. It was determined that the D90 dose was 60% of the prescribed dose. The physician and patient will be notified today, February 25, 2013.

The Iowa Department of Public health is planning an on-site inspection for February 27, 2013.

* * * UPDATE FROM DAHLIN TO KLCO ON 3/4/2013 AT 1257 EST * * *

The following information was received from the State of Iowa by email:

"...The post plan dosimetry was completed on February 25, 2013 where it was discovered that the D90 for the implant was 60%. The licensee immediately notified IDPH [Iowa Department of Public Health]. The patient and referring physician were also notified that same day. An IDPH inspector conducted an onsite investigation of the event on February 28, 2013. The inspector met with and interviewed the radiation oncologist, the medical physics staff and several hospital administrators. The inspector reviewed the patient chart including the written directive, the treatment pre-plan, the operating room notes and the treatment post plan. During the interviews and chart review it was determined that an additional nine I-125 seeds had migrated out of the prostate to an area slightly inferior to the prostate. The radiation oncologist and medical physics staff believe that the seed migration occurred along the needle path and was due to the bowel movement issues that the patient experienced post implant. Additionally, the treatment pre-plan was based on an ultrasound contoured prostate volume of 38.59 cc. The treatment post-plan was based on a CT scan contoured prostate of 21.61 cc. The urologist, radiation oncologist and medical physics staff determined that the D90 of 60% was due to the loss of the additional nine I-125 seeds that migrated out of the prostate and the shrinking of the prostate from 38.59 cc to 21.61 cc. The patient will receive an external beam boost to the prostate. In addition, the post-plan dosimetry showed that the rectum and bladder received a dose less than expected on the preplan. The radiation oncologist and urologist stated that the under dose to the prostate from the seed implant therapy will not have an adverse effect on the health of the patient. No corrective actions can be performed due to the licensee having no control over seeds that migrate out of the prostate."

Iowa Item Number: IA130001

Notified the R3DO (Valos) and FSME Resources via email.

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Non-Agreement State Event Number: 48784
Rep Org: ST JOSEPH REGIONAL MEDICAL CENTER
Licensee: ST JOSEPH REGIONAL MEDICAL CENTER
Region: 4
City: LEWISTON State: ID
County:
License #: 11-27371-01
Agreement: N
Docket:
NRC Notified By: DOUG HEIDORN
HQ OPS Officer: VINCE KLCO
Notification Date: 02/26/2013
Notification Time: 12:42 [ET]
Event Date: 01/18/2013
Event Time: [MST]
Last Update Date: 02/26/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3047(a) - EMBRYO/FETUS DOSE > 50 mSv
Person (Organization):
DON ALLEN (R4DO)
FSME RESOURCE(email) ()

Event Text

UNPLANNED IODINE-131 DOSE TO AN EMBRYO

A female patient with a previously removed thyroid, was treated for remnant thyroid cancer on January 18, 2013. She received an I-131 therapy dose of 58 mCi. On February 21, 2013, the radiation oncologist was informed by the primary physician that the patient had tested positive on a pregnancy test. The patient received an ultrasound on February 25, 2013 and the conception date was determined to be January 14, 2013. Based on the patient therapy activity received, an embryo dose of 15 Rem was calculated. Physician review of the ultrasound was determined to be normal for the embryo. The radiation oncologist is in contact with the primary physician and the patient.

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Fuel Cycle Facility Event Number: 48807
Facility: GLOBAL NUCLEAR FUEL - AMERICAS
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 TO UO2)
                   LEU FABRICATION
                   LWR COMMERICAL FUEL
Region: 2
City: WILMINGTON State: NC
County: NEW HANOVER
License #: SNM-1097
Agreement: Y
Docket: 07001113
NRC Notified By: SCOTT MURRAY
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 03/05/2013
Notification Time: 09:40 [ET]
Event Date: 03/05/2013
Event Time: 08:45 [EST]
Last Update Date: 03/05/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (a)(4) - ALL SAFETY ITEMS UNAVAILABLE
Person (Organization):
RANDY MUSSER (R2DO)
JANE MARSHALL (IRD)
BRIAN SMITH (NMSS)

Event Text

SOLE IROFS PRESSURE MAT DID NOT FUNCTION AS DESIGNED

"During a post maintenance test of a sole IROFS (Item Relied On For Safety) in the scrap press area, it was discovered that a sole IROFS of a pressure mat did not function as designed. The pressure mat is designed to ensure operator presence. The clutch that would be disengaged when the pressure switch is not active failed to do so. The press was immediately shut down. Similar presses have also been shut down. Double contingency was maintained (Moderation and Mass). The sole IROFS is designed for prevention of a fire scenario. At no time was an unsafe condition present."

There were no radiological or chemical hazards resulting from this event. The licensee is conducting an investigation to determine the cause of the failure.

The licensee has notified NRC R2 Inspectors and State and Local Agencies.

Page Last Reviewed/Updated Wednesday, March 06, 2013
Wednesday, March 06, 2013