ML20027B960
| ML20027B960 | |
| Person / Time | |
|---|---|
| Issue date: | 02/23/1982 |
| From: | Nussbaumer D NRC OFFICE OF STATE PROGRAMS (OSP) |
| To: | Cunningham R, Higginbotham L NRC OFFICE OF INSPECTION & ENFORCEMENT (IE), NRC OFFICE OF NUCLEAR MATERIAL SAFETY & SAFEGUARDS (NMSS) |
| Shared Package | |
| ML20027A639 | List: |
| References | |
| FOIA-82-335 810223, NUDOCS 8210120027 | |
| Download: ML20027B960 (1) | |
Text
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S UNITED STATES NUCLEAR REGULATORY COMMISSION
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WASHINGTON, D. C. 20555 FEB ' 31981
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2 MEMORANDUM FOR: Leo B. Higginbotham, Chief Radiological Safety Branch, IE R. E. Cunningham, Director Division of Fuel Cycle & Material Safety, NMSS FROM:
Donald A. Nussbaumer, Assistant Director for State Agreements Program Office of State Programs
SUBJECT:
HOSPITAL REPORT ON MISADMINISTRATION OF I-125 SEED IMPLANT THERAPY Enclosed is a copy of the report to St. Joseph's Hospital, Albuquerque, New Mexico, on the misadministration of I-125 seed implant therapy.
This was the subject of OSP Notice of Non-Routine Event No. 80-39 (Dec. 2,1980).
New Mexico has requested NRC assistance in-reviewing the report.
In partial response, we have arranged through IE, Region IV to make available to New Mexico the servic5s of William Hendee.
We request your review and comments on the report by c.o.b. February 27, 1981.
Both radiotherapists involved in the incident were certified in Radiology by the American Board of Radiology and it is our understanding that as such, under present NRC licensing practice, would be deemed qualified to use any of the sealed sources for therapy listed in 10 CFR 35.100,
- Schedule A, Group VI.
The hospital's report however, concluded that a 4
contributing cause was a lack of experience in I-125 implants on the part of the radiotherapists. The report also attributes the incidents to a lack of comunication between the developers of the treatment planning computer programs and its users. Although the report provides no details, we understand that this conclusion was reached after a determination that i
not all of the instructions'for use of the programs had been documented.
If you have any specific questions please contact Joel Lubenau or me, 27767.
4 Donald A. Nussbaumer Assistant Director for State Agreements Program Office of State Programs
Enclosure:
As stated
--A G g o g 27 820820
' DAVIES82-335
'PDR
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