NRC PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE
PNO-III-98-027

- March 20, 1998

PNO-III-98-027 Grandview Hospital

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 Region III staff (Lisle, Illinois) on this date.

Facility
GRANDVIEW HOSPITAL
Grandview Hospital
Dayton,Ohio
License No: SNM-1603

Licensee Emergency Classification
Notification of Unusual Event
Alert
Site Area Emergency
General Emergency
X Not Applicable

Subject: ACCIDENTAL INCINERATION OF A NUCLEAR POWERED CARDIAC PACEMAKER

On March 19, 1998, the Radiation Safety Officer of Grandview Hospital notified Region III (Chicago) and Headquarters that a Cordis Model 184-A, S.N. 651, pacemaker was accidentally incinerated after it was removed from a patient who had died on January 12, 1998. The pacemaker contained approximately 3 curies of plutonium-238 sealed inside two stainless steel and titanium capsules. The pacemaker was removed by a local mortician, and it was disposed of as part of ordinary bio-hazard trash.

According to the licensee, the mortician was not aware that the pacemaker contained a radioactive material. Subsequently, the bio-hazard trash was picked up by Stericycle, a waste broker, and it was transported to the BMWNC incineration facility in Charlotte, North Carolina.

The licensee did not learn of the patient's death until March 19, 1998. The licensee then notified BMWNC that the pacemaker had been among waste sent to it for incineration. BMWNC indicated that its radiation detector had not detected any increase of ambient background radiation at its incinerator. BMWNC is currently attempting to locate and recover the pacemaker.

The pacemaker is designed to withstand the temperatures occurring during cremation procedures without a breach of the doubly-encapsulated source. It is unlikely that the bio-hazard incineration would have damaged the integrity of the source.

Region III notified Region II (Atlanta) and NMSS of the incident. Region II, in turn, notified the State of North Carolina. North Carolina is an Agreement State with jurisdiction over radioactive materials in the State. The State is planning to perform radiation surveys at the incineration facility and monitor the effort to recover the pacemaker. The State of Ohio will also be informed. The information in this preliminary notification has been reviewed with the licensee.

The licensee notified the NRC Operations Center of this event at 4:57 p.m. EST on March 19, 1998. This information is current as of 9 a.m. on March 20, 1998.

Contacts:
TONY GO (630)829-9816
JOHN MADERA (630)829-9834

Source: Nuclear Regulatory Commission http://www.nrc.gov/OPA/pn/pn39827.htm