Event Notification Report for July 28, 2014
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/27/2014 - 07/28/2014
Agreement State
Event Number: 50321
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: COVENANT HEALTH SYSTEM
Region: 4
City: LUBBOCK State: TX
County:
License #: 06028
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: DONG HWA PARK
Licensee: COVENANT HEALTH SYSTEM
Region: 4
City: LUBBOCK State: TX
County:
License #: 06028
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/30/2014
Notification Time: 10:48 [ET]
Event Date: 07/28/2014
Event Time: 00:00 [CDT]
Last Update Date: 08/29/2014
Notification Time: 10:48 [ET]
Event Date: 07/28/2014
Event Time: 00:00 [CDT]
Last Update Date: 08/29/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
NEIL OKEEFE (R4DO)
FSME EVENTS RESOURCE (EMAI)
PAMELA HENDERSON (FSME)
NEIL OKEEFE (R4DO)
FSME EVENTS RESOURCE (EMAI)
PAMELA HENDERSON (FSME)
AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION DUE TO TREATMENT GIVEN TO WRONG PATIENT
The following information was obtained from the state of Texas via email:
"On July 30, 2014, the Agency was notified by the licensee that a patient had received a portion of a treatment intended for a different patient. The licensee's Risk Compliance Officer (RCO) stated two patients had arrived for treatment. Both patients were female of similar size. Both were to receive treatment to the brain, one patient to the right side and the other to the left side. The treatment head frame had been placed on both patients. It was decided that patient two would be treated first. This information was not provided to the individual entering the program into the treatment system so the program for patient one was entered into the treatment system. Patient two was placed on the treatment table and the treatment started. About two minutes into the treatment, a physician reviewing the treatment realized the wrong plan for the patient was being used and halted the treatment.
"The licensee determined the patient received 3.7 gray to 0.5 cc of brain tissue during the treatment. The patient and the patient's physician were notified of the error. The RCO stated the patient's doctor evaluated the event and stated the patient should not experience any adverse effects from the exposure. The patient was later treated using the correct treatment plan.
"The licensee has implemented several corrective actions as a result of the event. They include adding a second time out prior to treatment and requiring multiple staff to identify.
"The device was a Leksell Gamma System Model 24001 containing about 1800 curies of cobalt-60.
"Additional information will be provided as it is received in accordance with SA-300."
Texas Incident #: I-9217
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.
* * * UPDATE FROM ART TUCKER TO DONALD NORWOOD AT 1508 EDT ON 8/29/2014 * * *
The following information was received via E-mail:
"On July 30, 2014, the Agency [Texas Department of Health Services] was notified by the licensee that a patient had received a portion of a gamma knife treatment intended for a different patient. The incident was investigated at the facility and confirmed that a patient received a portion of a fractional treatment dose intended for another patient. The treatment time was for 2.68 minutes with a calculated total dose of 3.5 gray to the centerpoint maximum with 50% to the isodose lines at 1.75 gray to the wrong patient. The error occurred due to rescheduling patient one who had a much longer treatment time than patient two. The health physicist and radiation oncologist lacked communication with nursing staff regarding the switch to treat patient two before patient one. This communication error along with a lack of patient identification played a major role in the unintended treatment process. The facility completed a root cause analysis of the problem and self-reported the incident. Corrective actions have been implemented to include new policies and procedures incorporating better scheduling, patient identification practices to include 'time outs' during the treatment process and limiting distractions during the treatment procedure. No violations were cited."
Per the Texas Department of State Health Services, this event was not an Abnormal Occurrence as initially reported on 7/30/2014.
Notified R4DO (Pick) and FSME Events Resource.
The following information was obtained from the state of Texas via email:
"On July 30, 2014, the Agency was notified by the licensee that a patient had received a portion of a treatment intended for a different patient. The licensee's Risk Compliance Officer (RCO) stated two patients had arrived for treatment. Both patients were female of similar size. Both were to receive treatment to the brain, one patient to the right side and the other to the left side. The treatment head frame had been placed on both patients. It was decided that patient two would be treated first. This information was not provided to the individual entering the program into the treatment system so the program for patient one was entered into the treatment system. Patient two was placed on the treatment table and the treatment started. About two minutes into the treatment, a physician reviewing the treatment realized the wrong plan for the patient was being used and halted the treatment.
"The licensee determined the patient received 3.7 gray to 0.5 cc of brain tissue during the treatment. The patient and the patient's physician were notified of the error. The RCO stated the patient's doctor evaluated the event and stated the patient should not experience any adverse effects from the exposure. The patient was later treated using the correct treatment plan.
"The licensee has implemented several corrective actions as a result of the event. They include adding a second time out prior to treatment and requiring multiple staff to identify.
"The device was a Leksell Gamma System Model 24001 containing about 1800 curies of cobalt-60.
"Additional information will be provided as it is received in accordance with SA-300."
Texas Incident #: I-9217
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.
* * * UPDATE FROM ART TUCKER TO DONALD NORWOOD AT 1508 EDT ON 8/29/2014 * * *
The following information was received via E-mail:
"On July 30, 2014, the Agency [Texas Department of Health Services] was notified by the licensee that a patient had received a portion of a gamma knife treatment intended for a different patient. The incident was investigated at the facility and confirmed that a patient received a portion of a fractional treatment dose intended for another patient. The treatment time was for 2.68 minutes with a calculated total dose of 3.5 gray to the centerpoint maximum with 50% to the isodose lines at 1.75 gray to the wrong patient. The error occurred due to rescheduling patient one who had a much longer treatment time than patient two. The health physicist and radiation oncologist lacked communication with nursing staff regarding the switch to treat patient two before patient one. This communication error along with a lack of patient identification played a major role in the unintended treatment process. The facility completed a root cause analysis of the problem and self-reported the incident. Corrective actions have been implemented to include new policies and procedures incorporating better scheduling, patient identification practices to include 'time outs' during the treatment process and limiting distractions during the treatment procedure. No violations were cited."
Per the Texas Department of State Health Services, this event was not an Abnormal Occurrence as initially reported on 7/30/2014.
Notified R4DO (Pick) and FSME Events Resource.
Power Reactor
Event Number: 50315
Facility: HOPE CREEK
Region: 1 State: NJ
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: MICHAEL MOORE
HQ OPS Officer: HOWIE CROUCH
Region: 1 State: NJ
Unit: [1] [] []
RX Type: [1] GE-4
NRC Notified By: MICHAEL MOORE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 07/28/2014
Notification Time: 05:06 [ET]
Event Date: 07/28/2014
Event Time: 01:18 [EDT]
Last Update Date: 07/28/2014
Notification Time: 05:06 [ET]
Event Date: 07/28/2014
Event Time: 01:18 [EDT]
Last Update Date: 07/28/2014
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MEL GRAY (R1DO)
MEL GRAY (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 |
LOSS OF METEOROLOGICAL DATA TO THE SITE
"At 0118 [EDT] on 7/28/2014, meteorological data was lost to both Salem and Hope Creek. At the time, there were storms in the vicinity which [were] the apparent cause of the temporary loss of data. Both Salem and Hope Creek lost wind direction information. This event is being reported under 10CFR50.72(b)(3)(xiii), major loss of emergency assessment capabilities.
"At 0130, meteorological data was restored to the control rooms. Plant operations at Hope Creek and both Salem Units 1 and 2 were not affected. All three units remain at full power.
"The licensees notified the NRC Resident Inspectors."
"At 0118 [EDT] on 7/28/2014, meteorological data was lost to both Salem and Hope Creek. At the time, there were storms in the vicinity which [were] the apparent cause of the temporary loss of data. Both Salem and Hope Creek lost wind direction information. This event is being reported under 10CFR50.72(b)(3)(xiii), major loss of emergency assessment capabilities.
"At 0130, meteorological data was restored to the control rooms. Plant operations at Hope Creek and both Salem Units 1 and 2 were not affected. All three units remain at full power.
"The licensees notified the NRC Resident Inspectors."