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Event Notification Report for July 18, 2014

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/16/2014 - 07/18/2014

** EVENT NUMBERS **


50267 50268 50269

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Agreement State Event Number: 50267
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: LEHIGH VALLEY HOSPITAL - HAZLETON
Region: 1
City: HAZLETON State: PA
County:
License #: PA-0106
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/10/2014
Notification Time: 14:35 [ET]
Event Date: 11/13/2013
Event Time: [EDT]
Last Update Date: 07/10/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANNE DeFRANCISCO (R1DO)
FSME EVENTS RESOURCE (FSME)

Event Text

AGREEMENT STATE REPORT - BRACHYTHERAPY UNDERDOSE

The following information was received via fax:

"This medical event (ME) was self-identified by the licensee during an audit. A patient who had undergone an iodine-125 (I-125) prostate brachytherapy procedure was reported to have a 'D90' dose of 43% of the written directive. The licensee radiation safety officer and physician are in contact regarding this ME. It is unknown at this time if the patient has been notified.

"The Department [Pennsylvania Department of Environmental Protection] is waiting for the required 15 day written report from the licensee. The Department will then conduct a reactive inspection."

PA Event Number: PA140017

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: 50268
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: UNIVERSITY OF ILLINOIS
Region: 3
City: CHICAGO State: IL
County:
License #: IL-01883-01
Agreement: Y
Docket:
NRC Notified By: DARREN PERRERO
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 07/10/2014
Notification Time: 15:33 [ET]
Event Date: 07/08/2014
Event Time: [CDT]
Last Update Date: 07/10/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID HILLS (R3DO)
FSME EVENTS RESOURCE (FSME)

Event Text

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following information was received via fax:

"On July 9, the licensee's radiation safety officer called to report a potential medical event had occurred the previous afternoon. The Agency was advised that an interstitial treatment could not be completed involving a High Dose Rate afterloader (HDR) at the University of Illinois at Chicago. As a result of safety features built into the HDR's programming, the first fraction of a four fraction treatment of 300 rad was automatically terminated and the source returned to the safe/stored position after only 6 rad had been delivered when unexpected resistance was detected in the source wire as it moved to the second dwell position. Subsequent attempts to clear the path and reinitiate the treatment were unsuccessful. As a result, an underdose of 98% of the fraction occurred. The HDR unit was subsequently re-run through its quality assurance tests for positioning accuracy with no anomalies noted. The patient was notified of the event immediately.

"A week before, the patient had 3 catheters surgically placed near the pelvis and their location relative to the treatment site verified by CT scan with an additional scan just before treatment was initiated. After reviewing the scan the written directive was modified to call for 18 dwell positions in three channels for a duration of 101 seconds. Four fractions were going to be completed on successive days. The scan suggested the possibility of the catheters being moved as a result of distention of some internal organs. Although the 'dummy' wire successfully traversed the initial path, and the active wire reached the first treatment position, after the initial 2 seconds of programmed dwell time, the HDR unit detected an unexpected delay in the wire moving to the second dwell position, presumably due to constriction of the pathway, and automatically retracted the active wire to the safe store position. With the assistance of the manufacturer's off site technical advisor, the error code was cleared and attempts were made to reinitiate the treatment however, the 'dummy' wire could not traverse the path and the treatment abandoned.

"In this instance the device performed as designed and subsequent quality assurance tests confirmed the device was operating as expected. Although no effect on the patient is expected from the event, physicians are determining what course of treatment options are available at this time. The licensee was advised of the requirement to submit a written report of the event in accordance with the regulations. Pending additional developments and submission of the report, this matter remains open for now."

The HDR Afterloader has a 5 Ci Ir-192 source and was being used to treat a cancer in the pelvic area.

Illinois Report Number: IL14011

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: 50269
Facility: CRYSTAL RIVER
Region: 1 State: FL
Unit: [3] [ ] [ ]
RX Type: [3] B&W-L-LP
NRC Notified By: WILLIAM G. CARR
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/10/2014
Notification Time: 16:41 [ET]
Event Date: 07/10/2014
Event Time: 09:59 [EDT]
Last Update Date: 07/10/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
ANNE DeFRANCISCO (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 0

Event Text

NON-LICENSED EMPLOYEE SUPERVISOR FOUND IN VIOLATION OF FITNESS-FOR-DUTY POLICY

"A non-licensed employee supervisor has been found in violation of the Duke Energy Fitness for Duty Policy. The individual's access to the plant has been suspended. The licensee has notified the NRC Region 1 [Hammann]."

Page Last Reviewed/Updated Friday, July 18, 2014
Friday, July 18, 2014