U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
04/02/2003 - 04/03/2003
** EVENT NUMBERS **
39710 39721 39722
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|General Information or Other |Event Number: 39710 |
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| REP ORG: TEXAS DEPARTMENT OF HEALTH |NOTIFICATION DATE: 03/28/2003|
|LICENSEE: BAKER ATLAS |NOTIFICATION TIME: 12:15[EST]|
| CITY: HOUSTON REGION: 4 |EVENT DATE: 03/26/2003|
| COUNTY: STATE: TX |EVENT TIME: 07:30[CST]|
|LICENSE#: L05104 AGREEMENT: Y |LAST UPDATE DATE: 03/28/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |BLAIR SPITZBERG R4 |
| |TRISH HOLAHAN NMSS |
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| NRC NOTIFIED BY: GLENN CORBIN | |
| HQ OPS OFFICER: HOWIE CROUCH | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|NAGR AGREEMENT STATE | |
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EVENT TEXT
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| AGREEMENT STATE REPORT - INJURED AND CONTAMINATED EMPLOYEE TRANSFERRED |
| OFFSITE |
| |
| The following information was obtained from Texas Department of Health, |
| Bureau of Radiation Control via facsimile: |
| |
| "The Agency was notified that at 7:30 AM [CST] [on] 3/26/03, a neutron tube |
| blew apart inside the pulse neutron facility located at 2001 Rankin Road, |
| Houston, TX 77073-5114. The employee that was involved received superficial |
| lacerations. EMT's were notified at this time. Immediately after the |
| accident H-3 [tritium] contamination was found around the wound area. The |
| contamination was found in a swipe that was analyzed by the licensee using |
| their laboratory located on the premises. The swipe was found to have 19 |
| [nanocuries] of H-3 contamination. The employee was transferred by |
| ambulance to a local hospital. We believe at this time it was Memorial |
| Hospital. The EMT's and the hospital were made aware of the radiological |
| contamination and all precautions were taken. The licensee requested that |
| all materials removed or used at the hospital, and in the ambulance be |
| returned to the licensee. [Urinalysis] was [performed] on the employee and |
| found to be at baseline levels. Contamination was contained in the building |
| where the accident happened and contamination on the floor was |
| decontaminated to background levels. The licensee is following up with the |
| hospital concerning the contaminated clothing, and debris associated with |
| the incident. The licensee will submit a report within thirty days." |
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|Hospital |Event Number: 39721 |
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| REP ORG: MEDICAL CENTER OF BEAVER, PA |NOTIFICATION DATE: 04/02/2003|
|LICENSEE: MEDICAL CENTER OF BEAVER, PA |NOTIFICATION TIME: 08:51[EST]|
| CITY: BEAVER REGION: 1 |EVENT DATE: 03/31/2003|
| COUNTY: STATE: PA |EVENT TIME: 14:00[EST]|
|LICENSE#: 37-11562-01 AGREEMENT: N |LAST UPDATE DATE: 04/02/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |RONALD BELLAMY R1 |
| |TOM ESSIG MNSS |
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| NRC NOTIFIED BY: TONY COMBINE | |
| HQ OPS OFFICER: CHAUNCEY GOULD | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LOTH 35.3045(a)(3) DOSE TO OTHER SITE > SP| |
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EVENT TEXT
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| PATIENT RECEIVED A DOSAGE TO AN UNINTENDED TISSUE AREA |
| |
| The patient had a HDR (High Dose Rate) treatment using 4-9 curies of Ir-192 |
| when the tube was inserted into the treatment area it was 6 cms short of |
| going to the planned area to be treated. This was caused by the wrong |
| numbers being entered. It is estimated that the patient received between |
| 500 and 1,000 Rads to the wrong area. The patient and prescribing physician |
| were informed. There apparently was no adverse affects to the patient from |
| this error. |
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|Hospital |Event Number: 39722 |
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| REP ORG: UNIVERSITY OF MICHIGAN |NOTIFICATION DATE: 04/02/2003|
|LICENSEE: UNIVERISTY OF MICHIGAN |NOTIFICATION TIME: 11:46[EST]|
| CITY: ANN ARBOR REGION: 3 |EVENT DATE: 04/01/2003|
| COUNTY: STATE: MI |EVENT TIME: 16:00[EST]|
|LICENSE#: 21-00215-04 AGREEMENT: N |LAST UPDATE DATE: 04/02/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |BRENT CLAYTON R3 |
| |THOMAS ESSIG NMSS |
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| NRC NOTIFIED BY: MARK DRISCOLL | |
| HQ OPS OFFICER: ARLON COSTA | |
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|EMERGENCY CLASS: NON EMERGENCY | |
|10 CFR SECTION: | |
|LDIF 35.3045(a)(1) DOSE <> PRESCRIBED DOSA| |
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EVENT TEXT
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| MEDICAL EVENT INVOLVING ADMINISTRATION OF LESS THAN PRESCRIBED DOSE |
| |
| A physician prescribed a dose for an outpatient therapy at 25 millicuries of |
| Iodine 131. After completion of the treatment it was determined that the |
| patient actually received an exposure of 18.1 or 27.6% less than the |
| prescribed dose. The empty vials of Iodine 131 were re-assayed and 6.4 |
| millicuries of Iodine 131 apparently remained adhered to the glass vial. |
| The adherence of Iodine to the vial is being assessed by the Licensee and |
| NRC Region 3. The patient was notified of this incident by the attending |
| physician and the patient will return for administration of the remaining |
| dose. |
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