U.S. Nuclear Regulatory Commission
Operations Center
Event Reports For
05/22/2003 - 05/23/2003
** EVENT NUMBERS **
39868 39876
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|General Information or Other |Event Number: 39868 |
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| REP ORG: OK DEQ RAD MANAGEMENT |NOTIFICATION DATE: 05/20/2003|
|LICENSEE: OKLAHOMA UNIVERSITY MEDICAL CENTER |NOTIFICATION TIME: 19:13[EDT]|
| CITY: OKLAHOMA CITY REGION: 4 |EVENT DATE: 05/05/2003|
| COUNTY: STATE: OK |EVENT TIME: [CDT]|
|LICENSE#: OK-21035-01 AGREEMENT: Y |LAST UPDATE DATE: 05/20/2003|
| DOCKET: |+----------------------------+
| |PERSON ORGANIZATION |
| |TROY PRUETT R4 |
| |JOHN HICKEY NMSS |
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| NRC NOTIFIED BY: PAM BISHOP | |
| HQ OPS OFFICER: MIKE RIPLEY | |
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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 - MEDICAL MISADMINISTRATION |
| |
| The licensee reported a medical misadministration involving High Dose Rate |
| brachytherapy MammoSite treatment to a 70-year old female. Upon |
| administering the first of ten planned fractions it was noticed that the |
| Ir-192 source did not reach the center of the balloon but was near the |
| periphery 30 millimeters from the center. The patient dose was reassessed |
| and it was determined that the dose to the target area was less than planned |
| (56% of the planned dose). The patient and the patient's physician were |
| notified. It has been determined that there were no adverse effects to the |
| patient. Corrective actions will address four factors contributing to the |
| misadministration: wrong orientation of the patient during a CT scan; delays |
| in issuing the treatment plan due to a computer network failure; |
| mis-communications regarding the specified treatment plan; and similarities |
| between CT-based and radiographic-based printouts. |
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|Power Reactor |Event Number: 39876 |
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| FACILITY: OYSTER CREEK REGION: 1 |NOTIFICATION DATE: 05/22/2003|
| UNIT: [1] [] [] STATE: NJ |NOTIFICATION TIME: 12:32[EDT]|
| RXTYPE: [1] GE-2 |EVENT DATE: 05/22/2003|
+------------------------------------------------+EVENT TIME: 12:00[EDT]|
| NRC NOTIFIED BY: F. CIGNAIK |LAST UPDATE DATE: 05/22/2003|
| HQ OPS OFFICER: JOHN MacKINNON +-----------------------------+
+------------------------------------------------+PERSON ORGANIZATION |
|EMERGENCY CLASS: NON EMERGENCY |ANTHONY DIMITRIADIS R1 |
|10 CFR SECTION: |MICHELE EVANS IRO |
|APRE 50.72(b)(2)(xi) OFFSITE NOTIFICATION | |
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+-----+----------+-------+--------+-----------------+--------+-----------------+
|UNIT |SCRAM CODE|RX CRIT|INIT PWR| INIT RX MODE |CURR PWR| CURR RX MODE |
+-----+----------+-------+--------+-----------------+--------+-----------------+
|1 N N 0 Refueling |0 Refueling |
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EVENT TEXT
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| WORK STOPPAGE BY IBEW LOCAL 1289 UNION. |
| |
| IBEW Local 1289 Union personnel implemented a work stoppage and started |
| exiting the site at 1200 hours this date (05/22/03). Required watch |
| stations are being relieved by management personnel. |
| |
| The NRC Resident Inspector was notified of this event by the licensee. |
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