PNO-I-98-063, on 981217,licensee Medical Physicists Contacted NRC Operations Ctr to Rept Failure of Nucletron Selectron Ldr Remote Afterloader to Reimplant Cs-137 Sources in Patient Undergoing Brachytherapy.State of CT Informed
| ML20198C220 | |
| Person / Time | |
|---|---|
| Site: | 03001246 |
| Issue date: | 12/18/1998 |
| From: | Courtemanche S, Dwyer J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| References | |
| PNO-I-98-063, PNO-I-98-63, NUDOCS 9812210366 | |
| Download: ML20198C220 (2) | |
m. ,
DCS No.: 03001246981215 l
Date: December 18, 1998 PRELIMINARY NOTIFICATION OF. EVENT OR UNUSUAL OCCURRENCE PN1-I-98-063 This preliminary notification constitutes EARLY notice of events of POSSIBLE safety or public 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: St. Francis Hospital & Med.Ctr. Licensee Emergency Classification:
.. 114~ Woodland Street Notification of Unusual Event Hartford. CT 06105 Alert Site Area Emergency General Emergency X Not Applicable
' Docket.No.: 030-01246 License No.: 06-00854-03 1
. Event No.: .
Event Location Code: HOSP J
SUBJECT:
FAILURE OF A NUCLETRON SELECTRON LDR REMOTE AFTERLOADER TO REIMPLANT BRACHTHERAPY SOURCES l
l
-On December 17, 1998, the licensee's medical physicist contacted the NRC Operations l
. Center to report the failure of a Nucletron Selectron LDR Remote Afterloader to 1 reimplan+ esium-137 sources. in a 3atient undergoing brachythera)y. This failure resulted m a misadministration. 4RC Region I staff contacted tie licensee on December 17, 1998 to obtain additional information. A patient was being treated at the
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licensee's facility on December 15, 1998 about 3:30 p.m. when licensee personnel stopped the procedure and entered the room. After exiting the room, licensee Jersonnel attempted to restart the LDR and the computer displayed an error message and tie source did not come out. The patient was sent home after receiving only 90 centigray of a planned 2348 centigray dose. -The licensee determined that the above situation was a misadministration on December 16. 1998 after reviewing the records. The manufacturer's field service enginner was called in but could not determine what was preventing the source from going to the desired location. The engineer will continue to examine the ;
device on November 18, 1998 to try to determine what is causing the malfunction. l The State of Connecticut has been informed. !
The Region I Office of Public Affairs is available to respond to media inquiries.
Region I will continue to monitor the licensee's actions to determine the cause of the malfunction.
'All information is current as of 1:30 p m. on December 17, 1998.
Contacti S. Courtemanche J. Dwyer (610) 337-5075 (610)337-5309 f
9812210366 981218 PDR IEE i PNO-I-98-063 PDR t
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Chairman Jackson
Comm. Diaz ACRS Comm. McGaffigan Jr.
EDO OE OSP NRR' SECY l Regional Offices RI Resident Office Licensee:
(Reactor Licensees)
- General list for sending PNs by FAX Region I Form 83 (Rev. July 14, 1997) l 1
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