United States Nuclear Regulatory Commission - Protecting People and the Environment
Home > NRC Library > Document Collections > Reports Associated with Events > Event Notification Reports > 2013 > November 13

Event Notification Report for November 13, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/12/2013 - 11/13/2013

** EVENT NUMBERS **


49501 49528

To top of page
!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State Event Number: 49501
Rep Org: RESEARCH MEDICAL CENTER
Licensee: RESEARCH MEDICAL CENTER
Region: 3
City: KANSAS CITY State: MO
County:
License #: 24-18625-01
Agreement: N
Docket:
NRC Notified By: STEPHEN SLANICK
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 11/04/2013
Notification Time: 17:45 [ET]
Event Date: 11/04/2013
Event Time: 10:00 [CST]
Last Update Date: 11/08/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
CHRISTINE LIPA (R3DO)
FSME EVENT RESOURCE (EMAI)

Event Text

MEDICAL EVENT INVOLVING OVEREXPOSURE TO BLADDER DURING PROSTATE TREATMENT

During a prostate cancer treatment, at 1000 hours [CST] on 11/04/13, it was discovered that one I-125 strand with 6 seeds was improperly inserted into the bladder. The patient's prescribed dose was 144 gray to the prostate with a 12% exposure to the bladder. The procedure to the prostate was completed with extra I-125 seeds and the estimated dose to the bladder is 18%. It is believed that shadowing from the urethra, during treatment, was the cause. An attempt to withdraw the seeds from the bladder when the problem was identified was unsuccessful. The patient has been informed and the patient's physician will be informed and will consult with the urologist as soon as possible to determine a method for seed retrieval.

* * * UPDATE ON 11/8/13 AT 1150 EST FROM STEPHEN SLACK TO DONG PARK * * *

The following was received via email:

"The event took place during an implant of I-125 seeds into the prostate of a patient. One strand of six seeds was instead implanted into the bladder. Attempts to remove the strand of seeds at that time were unsuccessful.

"Renewed attempts were made to remove the strand this morning and they were successful. The implant was planned for 144 Gy to the prostate over the full decay time of the I-125. This would have resulted in a mean dose to the bladder of 22.34 Gy. If the extra seeds had remained in place, the mean dose to the bladder would have been 39.15 Gy; hence the report of a Medical Event.

"By removing the seeds this morning, the mean dose to the prostate has been reduced to 23.09 Gy. This is more than 50 rads to the organ but less than a 50% increase over what the organ would have gotten in the planned treatment."

Notified R3DO (Riemer) and FSME Events Resource via email.

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.

To top of page
Power Reactor Event Number: 49528
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [ ] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: JOE HESSLING
HQ OPS Officer: JEFF ROTTON
Notification Date: 11/12/2013
Notification Time: 01:23 [ET]
Event Date: 11/12/2013
Event Time: 00:02 [EST]
Last Update Date: 11/12/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
ALAN BLAMEY (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 90 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP DUE TO UNISOLABLE LEAK IN DIGITAL ELECTRO-HYDRAULIC SYSTEM

"At 0002 EST, Unit 1 Manually tripped the Reactor from 90% power due to an unisolable leak in the Digital Electro-Hydraulic [DEH] System. All CEAs fully inserted into the Reactor Core. All systems responded as expected on the trip. Decay Heat removal currently using Main Feedwater and Steam Bypass Control System. After the trip, DEH pumps were secured to stop the transfer of fluid from the DEH system to the Turbine Building. Investigation ongoing to determine exact location of the leak. This condition is reportable pursuant to 10CFR50.72(b)(2)(iv)(B)."

The was no impact on Unit 2. The NRC Resident Inspector has been notified.

Page Last Reviewed/Updated Wednesday, November 13, 2013
Wednesday, November 13, 2013