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Category:PRELIMINARY NOTIFICATION OF EVENT OR OCCURRENCE (PNO
MONTHYEARPNO-I-96-056, on 960806,licensee Called NRC Operations Ctr to Rept Loss of Seeds.Licensee Continuing Search & Investigation of Cause of Incident,Including Adequacy of Procedures for Retrieval,Accounting & Inventory1996-08-0707 August 1996
PNO-I-96-056:on 960806,licensee Called NRC Operations Ctr to Rept Loss of Seeds.Licensee Continuing Search & Investigation of Cause of Incident,Including Adequacy of Procedures for Retrieval,Accounting & Inventory
PNO-I-93-004, on 930121,therapeutic Misadministration Occurred Involving Administration of Brachytherapy Treatments to Rectum Instead of Vaginal Cavity.Patient Notified of Error.Incident Under Evaluation1993-01-22022 January 1993
PNO-I-93-004:on 930121,therapeutic Misadministration Occurred Involving Administration of Brachytherapy Treatments to Rectum Instead of Vaginal Cavity.Patient Notified of Error.Incident Under Evaluation
PNO-I-92-073, on 921202,discovered That 35 Mci Cs-137 Source Missing.Licensee Representative Sent to Perform Survey of Hosp Laundry Svcs Facility in Mildford,Ct.Source Recovered from Washer at Facility & Returned to Hosp1992-12-0303 December 1992
PNO-I-92-073:on 921202,discovered That 35 Mci Cs-137 Source Missing.Licensee Representative Sent to Perform Survey of Hosp Laundry Svcs Facility in Mildford,Ct.Source Recovered from Washer at Facility & Returned to Hosp
PNO-I-89-022, on 890310,Region I Notified That 25 Mci Cs-137 Source Retrieved from Trash Rejected by State of CT Disposal Facility on 890309.State of CT Notified1989-03-13013 March 1989
PNO-I-89-022:on 890310,Region I Notified That 25 Mci Cs-137 Source Retrieved from Trash Rejected by State of CT Disposal Facility on 890309.State of CT Notified
1996-08-07
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Category:TEXT-INSPECTION & AUDIT & I&E CIRCULARS
MONTHYEARPNO-I-96-056, on 960806,licensee Called NRC Operations Ctr to Rept Loss of Seeds.Licensee Continuing Search & Investigation of Cause of Incident,Including Adequacy of Procedures for Retrieval,Accounting & Inventory1996-08-0707 August 1996
PNO-I-96-056:on 960806,licensee Called NRC Operations Ctr to Rept Loss of Seeds.Licensee Continuing Search & Investigation of Cause of Incident,Including Adequacy of Procedures for Retrieval,Accounting & Inventory
PNO-I-93-004, on 930121,therapeutic Misadministration Occurred Involving Administration of Brachytherapy Treatments to Rectum Instead of Vaginal Cavity.Patient Notified of Error.Incident Under Evaluation1993-01-22022 January 1993
PNO-I-93-004:on 930121,therapeutic Misadministration Occurred Involving Administration of Brachytherapy Treatments to Rectum Instead of Vaginal Cavity.Patient Notified of Error.Incident Under Evaluation
PNO-I-92-073, on 921202,discovered That 35 Mci Cs-137 Source Missing.Licensee Representative Sent to Perform Survey of Hosp Laundry Svcs Facility in Mildford,Ct.Source Recovered from Washer at Facility & Returned to Hosp1992-12-0303 December 1992
PNO-I-92-073:on 921202,discovered That 35 Mci Cs-137 Source Missing.Licensee Representative Sent to Perform Survey of Hosp Laundry Svcs Facility in Mildford,Ct.Source Recovered from Washer at Facility & Returned to Hosp
PNO-I-89-022, on 890310,Region I Notified That 25 Mci Cs-137 Source Retrieved from Trash Rejected by State of CT Disposal Facility on 890309.State of CT Notified1989-03-13013 March 1989
PNO-I-89-022:on 890310,Region I Notified That 25 Mci Cs-137 Source Retrieved from Trash Rejected by State of CT Disposal Facility on 890309.State of CT Notified
1996-08-07
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DCS No: 03001244890313'
- Date
- March 13, 1989 PRELM4INARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE--PNO-I-89-022 '
SThis : preliminary notification constitutes EARLY notice of events 'of. POSSIBLE safety-ortpublic interest. significance. .The information~is as initially received without
- verification or' evaluation, and is basically all that is known by the Region I staff on this date.
Facility: . ..
Licensee EmergencyfClassification:-
7 Yale-New Haven Hospital Notification of Unusual. Event
- New Haven, Connecticut Alert Docket No. 030-01244- Site Area. Emergency
. General Emergency X Not Applicable-
Subject:
Retrival of Discarded Cesium-137 Source On' March'10' 1989 at 4:45 P.M. Yale-New Haven Hospital's Radiation Safety Officer (RS0) notified Region I that a 25 millicurie cesium-137 brachytherapy source was retrieved lfrom trash that was' rejected by a Connecticut Regional Waste ~ Disposal facility on March 9,z 1989.because of measurable radiation levels. The Radiation Safety Officer
. stated that, on March 9,1989,. he received notification of the trash rejection and went
.to the site, surveyed the trash and measured radiation levels of up to 12 millirem per hour. A check was made at the. hospital for misplaced'or lost sources and generators,
-but no loss.was identified. On March 10, 1989 a' decision was made tol sort the trash.
The source was located in a plastic bag. The cesium-137. brachytherapy source was from a 3M Heyman-afterloading applicator.- The inventory made after the last use of the brachytherapy device. failed to detect. that the applicator was- broken where:the, source .
capsule'is brazed to the. applicator rod. The licensee failed to survey the patient's i room after the sources were removed from the patient. i i
The. State of Connecticut has been notified. An inspector from the State was on site i
- during the efforts to recove the source from the trash. 1
/ j Region I will review this incident at an inspection to be scheduled in the near future.
Region I is prepared to respond to~ media inquiries.
This information is current as of 2:00 p.m., March 13, 1989. i CONTACT: T. Darden J. Glenn 346-5245 346-5209 8903210369 890313 PTIR ISE PDC PNO-I-89-022
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CA NRR OGC OIA ' Regional Offices GPA . 01 RI P.esident Office PA SLITP EDO OE Licensee:
(Reactor Licensees). !
Region I Form 83 (Rev. April 1988) s' i
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