United States Nuclear Regulatory Commission - Protecting People and the Environment

Morning Report for October 28, 1999

                       Headquarters Daily Report

                         OCTOBER 28, 1999

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                    REPORT             NEGATIVE            NO INPUT
                    ATTACHED           INPUT RECEIVED      RECEIVED

HEADQUARTERS                           X
REGION I            X
REGION II                              X
REGION III                             X
REGION IV                              X
PRIORITY ATTENTION REQUIRED  MORNING REPORT - REGION I  OCTOBER 28, 1999

Licensee/Facility:                     Notification:

                                       MR Number: 1-99-0041
St. Peter's Medical Center             Date: 10/27/99
New Brunswick,New Jersey               NRC Operations Center
Dockets: 03002502 License No: 29-07566-01

Subject: BRACHYTHERAPY INCIDENT

Discussion:

On October 27, 1999, the licensee notified the NRC Operations Center of
an incident during a brachytherapy procedure.  At 1300 hours on October
27, 1999, a patient undergoing a gynecological brachytherapy procedure,
raised her bed in order to have lunch.  When the patient raised the bed,
the brachytherapy applicator came out of its position and ended up
between the legs of the patient.  At 1315, as scheduled, the patient's
radiation oncologist came to remove the brachytherapy applicator and
discovered it laying between the legs of the patient.  The brachytherapy
applicator was removed by the physician.  The local area dose to the
patient's legs was calculated to be 22 rads.  The patient was scheduled
to receive 2000 rads to the treatment site, but instead received 1978
rads.  The patient's referring physician will be notified.  According to
the radiation oncologist the patient did not receive any adverse health
effects from this incident.

On October 28, 1999, an NRC inspector who was conducting an inspection at
another facility in the area is following up this incident.

Contact:  I. Czerwinskyj             (610)337-5311
          M. Shanbaky                (610)337-5209
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