ML20082M635

Office for Analysis and Evaluation of Operational DATA.1990 Annual Report - Nonreactors

ML20082M635
Person / Time
Issue date:	07/31/1991
From:	NRC OFFICE FOR ANALYSIS & EVALUATION OF OPERATIONAL DATA (AEOD)
To:
References
NUREG-1272, NUREG-1272-V05-N02, NUREG-1272-V5-N2, NUDOCS 9109050303
Download: ML20082M635 (96)

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.___m. AVAILABILITY NOTICE Availability of Reference Materials Cited in NRC Publications Most documents cited in NRC publications will be available from one of the following sourCOs: 1. The NRC Public Document Room, 2120 L Street, NW., Lower Level, Washington, DC j 20555 2. The Superintendent of Documents, U.S. Government Ponting Office. P.O. Box 37082. Washington, DC 20013 7082 3. The National Technical Information Service, Springfield, VA 22161 Although the listing that follows represents the majority of documents cited in NRC publica. tions, it is not intended to be exhaustive. Referenced documents available for inspection and copying for a fee from the NRC Public Document Room include NRC correspondence and internal NRC memoranda; NRC bulletins, circutars, information notices, inspection and investigation notices; heensee event reports: vendor reports and correspondence; Commission papers; and apphcant and licensee docu-ments and correspondence. The following documents in the NUREG series are available for purchase from the GPO Seles Program; formal NRC staff and contractor reports, NRC sponsored conference pre aed-ings, and NRC booklets and brochures. Also available are regulatory guides, NRC regula-tions in the Code of Federal Regulations, and Nuclear Regulatory Commission Issuances. l Documents available from the Nationa! Technical inforrnation Service include NUREG-series reports and technical reports prepared by other FoderM acencies and reports prepared by the Atomic Ene gy Cominission, forerunner sgsncy to it e Nuclear Pegulatory Commission. Documents available from public and speial technical IOraries include all oten literature items, such as books, journal articles, and transt~ os. Federal Register nottes, Federa' and State legislation, and congio.;Was recor' an usually be obtained from these libraries. Documents such as theses, dissertations, foreign reports and translations, enr1 non-NRC conference proceedings are available for purchrise from (*1e organization spon; 7 ting the publication cited. Single copies of NRC draft reports are availabs free, to the extent of supply, upon written request to the Office of Administration, Distobution and Mail Services Section, U.S. Nuclear Regulatory Commission Washington, DC 20555. Copies of industry codes and standam ' used in a substantive manner in the NRC regulatory process are maintained at the NRC Library, 7920 Norfolk Avenue, Bethesda, Maryland, for use by the pubhc. Codes and standa.*ds are usually copyrighted and may be purchased from the originating organization or, if they are American National Standards, from the American National Standards Institute,1430 Broadway, New York, NY 10018. l t-

1 vM"l"d"? O F F i C.E F 0 R

• 4-J ANALYSic AND EVALUATION OF OPERATIONAL DATA 4

1 i i ? d

l

.n . c e% / 48REGg% 1990 ANNUAL REPORT ! I ff a fl o NONREACTORS G wj U.S. NUCLEAR REGULATORY COMMISSION 4, c[ JULY 1991

• • • • +

The map on the cover highlights in white those States for which NRC continues to regulate the use of radioactive material in nonreactor applications. The other States have signed agreements with NRC allowing them to perform this role. l... - _ _ _.,___

_ = l Previous Reports in Series i The following semlannual or annual reports have been prepared by the Office for Analysis and Evaluation of Operational Data (AEOD): Semiannual Report, January-June 1984, AEOD/S405, September 1984 Semlannual Report, July-December 1984, AEOD/S502, April 1985 5 e Annual Report 1985, AEOD/S601, April 1986 I e Report to the U.S. Nuclear Regulatory Commission on Analysis and Evaluation of Operational e Data-1986, NUREG-1272, AEOD/S701, M I Report to the U.S. Nuclear Regulatory Commission on Analysis and Evaluation of Operational e Data-1987, Power Reactors, NUREG 1272, AEOD/S804, Vol. 2, No.1, October 1988 l Report to the U.S. Nuclear Regulatory Commission on Analysis and Evaluation of Operational i e Data-1987, Nonreactors, NUREG-1272, AEOD/S804, Vol. 2, No. 2, October 1988 Office for Anat sis and Evaluation of Operational Data 1988 Annual Report, Power Reactors, h t e NUREG-1272, Vol. 3, No.1. June 1989 Office for Analysis and Evaluation of Operational Data 1988 Annual Report, Nonreactors, e j NUREG-1272, Vol. 3, No. 2, June 1989 Office for Analysis and Evaluation of Operational Data 1989 Annual Repor1, Power Reactors, e NUREG-1272, Vol. 4 No.1, July 1990 Office for Analysis and Evaluation of Operational Data 1989 Annual Report, Nonreactors, F e NUREG-1272, Vol. 4, No. 2, July 1990 i l [ i i

Abstrac't The annual report of the U.S. Nuclear Regulatory reports, diagnostic evaluations, and reports to the Commission's Office for Analysis and Evaluation of NRC's Operations Center. NUREG-1272, Vol 5, Operational Data (AEOD) is devoted to the activates No. 2. covers nonreactors and presents a review of performed during 1990. The report is published in the events and concems during 1990 associated two separate parts. NUREG 1272. Vol. 5, No.1, with the use of licensed material in nonreactor covers power reactors and presents an overview of applications, such as personnel overcyposures and the operating experience of the nuclear power medical misadministrations. The reports contain a industry from the NRC perspective, including discussion of the incident investigation Team comments about the trends of some key program and summarize both the Incident performance measures. The report also locludes the investigation Team and Augmented inspection principal findings and issues identified in AEOD Team reports for that group of licensees. Each studies over the past year and summarizes volume contains a list of the AEOD reports issued information from such sources as lic..isco event for 1981 through 1990. i iii NUREG-1272

Coritents Abstract ill Abbreviations vil Executtvo Summary b: 1 Introduction 1 b 2 Feedback From Honreactor Licensee Operational Experience 3 2.1 Overview of Oporating Experience 3 2.1.1 Nonreactor Evems 3 2.1.1.1 Events Reported during 1990 3 2.1.1.2 Radiation Overrxposure Events 3 2.1.1.3 Other Types of Events.. 4 [ L 2.e.2 Modical M!sadminl>trations 4 2.1.2.1 Misadministra' ions Reported During 1990 5 2.1.2.1.1 Thorapy Misadministrations. 5 2.1.2.1.2 Diagnostic Misadministrations 5 2.1.2.1.3 Diagnostic Misadministrations cf lodino C 2.1.2.2 Misadministrations Reported From 1981 1990.... 0 2.2 Reporting of Abnormal Occurrenc0s.. 7 2.3 Completion of a Videotape on ' Good Practicos in Preparing and Administering Radiopharmaceuticals'.. 7 2.4 Solected Ongoing Technica! Studios.. 7 3 incident Investigation Psogram.. 9 3.1 'ncident investigation of the inadvertent Shipment of a Radiographic f,,ource frcm Korea to Amersham Corporation. Buriington, Massachusetts 9 3.2 Augmented inspection Team inspection of Water Contaminated With High Concontrations of Uranium Discovered During Excavation Work at the Sequoyah Fuels Corporation s Facility, Gore, Oklahoma. 11 4 Summary 3 Appendicos A Report on 1990 Nonreactor Events B Report on 1990 Misadministration Events C Summary of 1990 Abnormal Occurrences D Reports issusd From 1981 Througn 1990 E Status of AEOD Rocommendations F Status of NRC Staff Actions for Event investigated by incident investigation Team v NUREG-1272

1 Abbreviatioris AEOD NRC's Office for Analysis and Evaluation ilP inck1ont investigation Program of Operational Data llT Incktont investigation Toam AIT Augmented inspection Team NRC U.S. Nuclear Regulatory Commission AO abnormat occurrenco NRER nontoactor ovent report CFR Code of fodoral Regulaflons SFC Sequoyah Fuels Corporation DOT Department of Transportation SNM specla! nuclear material EDO NRC's Exocutive Director for Operations 3X soNont extraction I 4 a 5 f I i i. I vil NUREG+1272

Emcutivo Summary One of the activities of the Office for Analysis ard During 19'O, the itudvertent shipment of a radio. Evaluation of Operational Data (AEOD) is the review graphic source itom Korea 1o Amersham and evaluation of operating experience of non-Corporation located in Durhngton, Massachusetts, reactor programs involving the use of rnaterials was the subject of an onsite review by an incklent o licensal by the U S. Nuclear Ragulatory invest gation Team (IIT). While the lovestigatbn Commission (NRC), such as source material, natural concluded that no actual overexposures resulted and enrich (d uranium, arxl byproduct rnatorials T he frorn the event, it dd raiso questions concerriing the AEOD review arx1 evaluation kjentifies safety signifi-adequacy of regulations for transport of radioactive cant events and concerns, their causes, ard the material. All action items identified in the llT are trends indicated by the events, When AEOD identi trachd until resolution fies a safety concom, the AEOD staff recommerxis agency actions to resolve the problems undertying the safety concern. In 19 % the NRC corducted an Augmented Inspection Tearn (AIT) review in response to an event at the Sequoyah fuels Corporation facility, in Many of the states have entermi into agreements which a large amount of uranium in solution was with NRC to manage the use of byproduct discovered in an excavation on site. T he sources of materials, natural uranium, and small arnounts of the contamination which had seeptd onto the enrichmj uranium or other special nuclear materials. grourx1 over rnany years have twan oliminated. The These states, known as Agreement States, oversee initial investigation of the ground water in the vicinity the pograms run by their hconsees. NRC bconsees of the excavation Indicated that contamination had comprise about 30 to 40 percent of the total not migrated off the site arxl had not come into number of ticensocs in both NRC-regulated states contact with any aquifers that may be ustd by the and Agreement States. public. Approximately 8000 licensees are authorized by the Of the 467 misadministration reports received during NRC to possess arxl uso licensmi materials outskio 1990, which involval 573 patients, 443 reports of reactors The majority of licensees (about 5500) concemed diagnostic misadministrations and 24 are authorized to use byproduct matenals for such concemed therapy misadministrations, in addition applications as radiography, gauges, arxi well to tho 24 therapy misadministrations there were two logging. Approximately 2400 licensees are diagnostic misadministrations of kxlino 131 in 1990 mJthortied to administer byproduct materials or in which patients received thyroid doses of more radiation from byproduct materials to individuals for than 1000 rads, a doso far in excess of the dose for medical diagnosis or therapy. the dia0nostic procalures for which they were schaluled The dominant health concern associated with the use of licensed materials is the possiblo damage The staff estimates that about 7 mi' lion dia0nostic that can occur from overexposure to radiation In procedures and 180,000 therapy procodures are 1990, 24 nonreactor events were reported to the performed each year, with about 40 percent of NRC in which 30 lrxilviduals toccived exposures that those proceduros being periormed by NRC were greater than those permitted by NRC regula-licensees 6nd the romainder by Agrooment State tions All of the irgilykluals were associated with licensees Thenumberof thorapymisadministrations licensees. Most of those overexposures represent reportmi during 1990 was about three times the exposures that exceed the onartorty regulatory hmits average number reported in the prior 9 years; arxl by a small amount There were four exposures to the number of diagnostic reports also exceed &l the radiographers :n which irxlividuals receiwd prior 9 year average by about 10 percent. However, extremity or local exposures that ranged from 100 desprte these increases in the numbers of to several thousarx1 rem lx NUREG 1272

i AEOD Annual Report, tWO reportable events, the error rato for all types of types of orrors. Tho videotape illustrates good misadministrations remainod very low. practicos that are designed to avoid errors in preparing and aoministering radiopharmaceuticals. The staff developed tho vidoo with support from The error rate for therapy misadministrations rangod Oak Ridge Associated Universities and Argonno from 0.0002 por procedure for brachytherapy and National Laboratorios. The information prosented radiopharmaceutical therapy to 0 0003 per patient recognlies the commitment of the medical ior telethorapy; the error rato for diagnostic misadm-professional community and the NRC to good inir,trations reported was about 0.0001 por medical practices involving byproduct materials. procedure. In 1990, AEOD produced a videotape on good Copios of the videotape have boon distributed to all practices in preparing and administering radiophar-NRC medical licensoos and regulatory agenclos for macouticals. This videotape utilized data from Agrooment States. reported modical misadministrations to identify those practius that result in the most frequent h l NUREG 1272 x

1 Introduction The NRC licensos the use of reactor produced Commission's earliest major efforts toward isotopes, the milling of uranium, and the subsequent improving the use of licensee operating experience i processing of either natural or onriched uranium to kjentify and resolve problems with potential ard special nuclear material (SNM). Many of the safety-relat(d implications states have enterod into agrooments with NRC to manago the use of byproduct materials, natural uranium, and small amounts of enriched uranium or The role of AEOD in the regulatory process is to other special nuclear materials. T hese states. known provido a capability for the timely collection and as Agreement States, oversos the programs run by analysis of operating experience, independent of the their licensees NRC licenseos comprise about 30 to routine regulatory actMtics associated with 40 percent of the total number of licensees in both licensing. Inspection, or enforcement, and to feed NRC-regulated states ard Agrecment States back the lessons loamed to the appropriato offices of the NRC, the affected portions of the industry, and the public. AEOD implements this role in the The NRC has approximately 8000 licensees nonroactor area through tho analysis and ovaluation authorized to possess and uso futural uranium and of operational safety data associated with the uso of SNM (predominantly in support of the reactor fuel radioactive materials in nontoactor applications. Cycle) and byproduct materials of SNM. Of these AEOD publishes studies of specific operational licenseos, about 5500 are authorized to use events and, as appropriato, recommends agency byproduct materials for such applications as actions to reduce the probability that those events radio;;raphy, gaugos, and welllogging About 2400 will recur with the same frequency or will load to modical licensees are authorized to administer more serious events, byproduct materials or radiation from these materials to indMduals for medical diagnosis or i therapy A relatively small number of licensees use AEOD also administers the incident Investigation uranium or SNM in fuel cycle operations. Program (IIP), an activity to ensure that NRC investigations are timely, well coordinated, and formally administored. incidents of potentigdy najor NRC nonreactor licensees are required to report safety significance are investi0ated by incident events such as those involving a personnel investigation teams (IIT) directed by headquarters overexposure (10 CFR 20 405(a)), a leaking or offices. Incidents of less significanco are contaminated source (10 CFR 34 25,10 CFR 3514); investigated by augmented inspection teams (AIT) release of material (to CFR 20.405(a)); lost or stolen directed by the NRC regional officos. materials (10 CFR 20.402); or abandoned well-logging sources (10 CFR 39.77). Events may also be reported as required by a license condition or AEOD tracks tho rocommendations and staff actions may be included in an inspection report. About 300 contained in its studios and ilT reports until they are reports of such events are received annually, or resolved. The appropriato NRC piogram office or about 6 events per 100 licensoes. Similarly, the 2400 regional office acts on those recommendations and medical licensces repori about 400 actions. The office to which the recommendation or misadministrations annually or about 16 events per action is addressed is responsible for resc4ving it. 100 licensees Generally, these licensed programs have little negative impact on public health and safety. AEOD keeps informed of studies undertaken by other organizations with!n NRC and normally will not duplicato a study unloss a particular need or special Role of AEOD circumstanco exists Thus, the nontoactor staff of AEOD does not review in depth all nonroactor events or operating problems. AEOD was established in 1979, reporting directly to the Executive Director for Operations, as one of the i NUREG 1272, Section 1

AEOD Annual Roport,1990 F AEOD also coordinatos the overall NRC oporational App 9ndix B, Report on 1990 Misadrninistra-data program ard serves as the contral point for tion Evonts intoraction with domestic and foreign organizations performing similar work. l Appendix C, Summary of 1990 Abnornal l Occurronces i The 1990 AEOD Annual Report is publishcd in two separate parts: Power floactors and Nontoactors. The report on Nontoactors, Vol. 5, No. 2, is an over. Appondix D, Nontonctor Reports issuod From view of events reportod by nonroactor licensoos 1981 Through 1990 during 1990, together with a report on the activities of an lli and an AIT in the nonroactor area. i Appendix E, Status of AEOD Recommendations Moro detall on tht events reported by nontoactor licensoes will be fot M in the following appendices: [ Appordix F Status of NRC Staff Actions for the Event Investigated by incident + Apperv.,9 A '2ept 1 & 1990 Nonreactor Investigation Team Events i f i I P i i l-l + i NUREG-1272, Section 1 2

2 Feedback From Nonreactor Licensee Operational Experience During 1990, the NRC rocolved toports on a largo recolvod exposures in excess of a regulatory limit number of events that involved NRC and licensees. specified in 10 CFR Part 20. All of thoso exposures This section provides an ovorview and summary of woro occupational exposures recolvod by indi-reported events involving nonroactor facilities and viduals in the course of their work. medical misadministrations that woro report (d in 1990. A separato report of ovents reporttd by Agroomont States will be issuod in lato 1991. The 24 ovents occurrod at different typos of licenseos; 7 woro reportod by modical and academic licenseos; 9 were reported by radio-2.1 Overview of Operating graphors; 4 woro reportod by commorcial and Experience irdustrial licensoos; I was reported by a fuol cycle licensoo; and 3 woro reported by Agroomont Stato licensees. 2.1.1 Nonreactor Events Modical and Academic The AEOD Nonroactor Event Report (NRER) database contains information on licensod nucioar The sovon ro;x>rts from those licenseos represent rnatoilals and fuol cycle oporational events and on or sures of @ WA ed d h personnel radiation exposure ovonts. The NRER tocotvod a doso in excess of the quarterly limits database managemont system prodios for input' s ociflod in the NRC regulations. Ono of the storage, retrieval, and computor assisted analysos ide molvod a doso that excoodod the of operational event data; the system may be used annual Hmit. to identify trends in operational safey events that may signal a nood for remodial actions by the NRC, liconsoes, or both. y g,g,og,np y 2.1.1.1 Events Reported During 1290 n throo of the nino events toported by radiography licensoos, Individuals rocolved dosos that were high enough for the t,vonts to be classified as Abr.onnal During 1990,309 records of events woro ontored Ocanenus (AOsh Two onWoyms of om radog-into the NRER database. Informaflon on those raphy licensoo woro exposed as the result of a events was contained in reports submittod by NRC s urce disconnoct. One of the individuals drapod a licensoos to the regional offices or in other docu-guido tubo containing the source around his nock monts, primarily in reports of inspections conducted and rocolved a local dose of more than 1000 rom to by NRC. The NRER database doos not include his neck. A radiographar employed by a diflorent information from reports of modical misadministra-Hanse romM a twd aposure in muss of tions. Section 2.1.2, *Modical Misadministrations,. 1000 rem when he grabbed a sourco guide tubo contains a discussion of thoso data for 1990. containing the sourco, and an employoo of a third radiography licensoo recolved a dost of sovoral thousaM rom to W Mnd ht resultW in sMn 2.1.1.2 Radiation Overexposure Events blistors. The NRC rocolved 34 reports of events during 1990 In a fourth event, an employee of a radiography in which there was the potential for or an actual Iconsoo recolved an extremity dose of up to 100 radbtion overexposure. Of the 34 events, 24 to Ns d de N Mbod a sono #o involved actual ovoroxposures. Thirty individuals 3 NUREG 1272, Section 2

AEOD Annual Report,1990 1 r tube to steady the radiography device when the 2.1.2 Medical Misadministrations source was not fully retracted The other 5 ovents concernod 10 indivkjual The NRC regulatos certain aspects of the uses of occupational exposures that excooded the quarterf y roactor produced radiolsotopos in nuclear modicino limit. and therapeutic radiology. Certain diagnostic and therapy rnisadministrations are reported to NRC as required in 10 CFR 35.2 and 10 CFR 35 33. Commercial and Industrial Diagnostic misadministration, as used in NRC regulations, refers to the misadministration of radioisotopos in nuclear modicino studios such as A licensoo reported that an employoo had recolved renal scans and bone scans, Therapy misadminis-a whole body dose of 3.7 rem when an explosion tration, as usod in NRC regulations, refors to the sprayed liquid containing carbon-14 on his arm; the misadministration of radiation from cobalt 60 Mrtan 14 was absortxd through the skin In throo tolotherapy or radioisotopos used for radiation other events, employoos of commercial and therapy. Industrial licenseos receivod occupational ex posures that exceeded the quarterly limit. An estimated 7 rnillion diagnostic nuctoar medicine procedures, 30,000 radiopharmacoutical thorat y Fuel Cycle proceduros (the ingestion or injection of radioactivo compounds for patient therapy treatment), ard 50,000 brachytherapy proceduros (the insortion or The event at a fuoi fabricator represents occupa* implantation of scaled sources containing tional exposures to extremities of throo individuals radioactivo material for patient therapy treatment) that excoodod the quartoriv allowab!e limit, are performed annually in the United States. In addition, about 100,000 patients receivo cobalt 00 tolotherapy treatments (oxternal use of radiation for Agrooment Stato Licensoes patient treatment) each year The NRC estimates that about 40 percent of all those proceduros are periormed by NRC licensees and 60 porcont by Two of the events reported from an Agrooment Agroomont Stato licensoos. Stato concerned occupational exposures that excooded the quarterly limits. In the third event, a student ingostod phosphorus-32. Over the last 10 years (1901-1990), modical facilities licensod by the NRC to use radioisotopos in nuclear medicino and radiotherapy for humans have boon 2.1.1,3 Other Types of Events required to report misadministrations. Another 2G5 reports of other classes of events wero Therapy misadministrations are associated with reviewod. These ovents included lost or stolen procoduros in which largo dosos of radiation are sourcos, abandoned sources, leaking or administered to patients to achiovo a therapeutic contaminated sources, consumer products, fuel offect. Diagnostic misadministrations are associated cycle facility events, industrial radio 0raphy, with proceduros designed to permit a diagnosis to manufacturing and distrib1 ion, and gaugos and be made with little exposure to the patient. An measuring systems. Two vents, the subject of exception to the usual diagnostic procedure is the enhanced investigations, ate discussed in Section 3. use of lodino 131, which may deliver 1o the thyroid ' incident investigation Program.' Generally, none of or an or0an a dose of soveral hundred to soveral the events had any reported adverso offect on thousand rom. public health and safety, AEOD's annual review of data on misadministrations has indicated that the number of reportrd NUREG 1272, Section 2 4

Nonreactors - Operational Experience diagnostic misadministrations shows no significant personnol, one occurrod because of miscLmmu-changa with timo. Hnwever, in 1990, the number of nication among the licenseo staff, md one was therapy misadmir'istrations was throo times higher caused by unintended removal of the source by the than the average number of the reported therapy patient. misadministrations from 1981 through 1939 For both types of misadministiations, implementation of quality assurance procedures - cither existing or Two of the radiopharmaceutical therapy misad-new - might effect an even Inwer frequency of ministratiom involved tho verification of tho labeling misadministrations. and the volume of the administered radiopharma-ceutical, one involved the verification of patient identification and the prescribed dosage, and two While it might be suggested that the uncertainty were caused by lack of training of involved person-band for calculated error rrtes may be large, the nel. low error rates calculated from reported data on misadministrations suggest that most licensed programs are operated in a way that rninimizes These types of therapy misadministrations might misadministrations. have been avoided if licensees had been following their already established quality assurance proco-dures or had improved their existing quality 2.1,2.1 MisadministrationsReported During 1990 assurance procedures For 1990, approximately 350 NRC licensees, 2.1,2.1,2 Diagnostic Misadministrations authorized to perform nuclear medicino studies or radiation therapy, reported one or more misadminis-trations, a total of 407 reports invoMng 573 As in previous years, essentially all of the diagnoshe patients. Of these reports,443 concerned diagnostic misadministrations Ior 1990 involved ei'her the misadministrations ard 24 concerned therapy administration of the wrong radiopharmaceutical or misadministrations. the administration of a radiopharmaceutical to the wrong patient. The number of diagnostic misadmini-strations in 1990 is about 10 percent greater than 2.1.2.1.1 Therapy Misadministrations the avercgo number received over each of the past 9 years. The causes reported by licensees are generally the same as those reported in the past, ~ Licensees reported 24 therapy misadministrations in that is, simple errors associated with procedures for 1990. Of these misadministrations,10 involved (1) ordering nuclear medicine, (2) preparing radio-telethorapy, 8 involved brachytherapy, and 6 pharmaceuticals, and (3) administering radiophar-involved radiopharmaceutical therapy. maceuticals. Of the toletherapy misadministrations, four involved Of the 443 reports of dia0nostic misadministrations an inadequate review of the patient's chart, two received in 1990, 71 percent involved the involved an error in identifying the correct patient, administration of the wrong radiopharmaceutical to two involved an error in the dose calculation, one a patient and 23 percent involved the administration involved an error during simulation, and one of a radiopharmaceutical to the wrong patient (these resulted in the administration of four excess two types of misadministrations accounted for 94 fractions of treatment as a result of human error. percent of the reported misadministrations). Two of the brachytherapy misadministrations in included in the remaining diagnostic 1990 were caused by incorrect data entered into the misadministrations were 20 that involved a computer that controlled the remote afterloading diagnostic dose of a radiopharmaceutical that device, two involved treatment to the wrong area of differed from the prescribed dose by greater than 50 the patient's body, two were caused by equipment percent, and 8 that involved the wrong route of malfunction, one was due to lack of training of administration (i e., a route of administration other 5 NUREG-1272, Section 2

y AEOD Annual Report,1990 than that intended by the proscribing physician). Of 2.1.2.1,3 Diagnostic Misadministrations of the 443 reports of diagnostic misadministratk>ns,13 lodina involved the misadministration of lodine 131. These misadministrations are discussed in more detail in Section 2.1.2.1.3,

• Diagnostic Misadministrations of Of the dia0nostic misadministrations reported to the lodine?

NRC in 1990,13 involved the administration of lodine-131 in amounts that resulted in the delNory it should be noted that the threshold for reporting of patient organ doses that ranged from 10 mrada diagnostic misadministrations was revised in 1987. to 3400 rads. Causes of those misadministrations ) In accordance with the new requirements of 10 CFR included (1) the wrong dosage listed in the depart-35 33, diagnostic misadministrations occurring after ment's proceduto manual, (2) misunderstanding the April 1,1987, nood be reported only if - referring physician's request, (3) ordoring the incorrect dosage from a radiopharmacy, (4) not the misadministration involved the use of radio-checking the patient's chart, (5) sc4ecting the wrong e actNo material not intended for modical use, vial when drawing dosage, and (6) misroading the dose calibrator. the administered dosago was fNo-fold different from the prescribed dosage, or Two of these misadministrations resulted in estimated thyroid dores of 3400 and 1800 rads. In one caso, the wrong dose for a study was entored the patient was likely to receive an organ dose in the hospital's procedure manual; in the second greater than 2 rem or a wholo-body dose case, a tolophone order from a physician was groater than 500 mrom, misinterptoted. The change in reporting requirements for diagnostic 2.1.2.2 Misadministrations Reported From misadministrations has not reduced the number of 1981-1990 misadministrations reported to the NRC. The number reported annually rangod from 332 to 433 before 1987 and from 386 to 430 since 1987. Table 1 and 2 of Appendw D show the number of Because the dose for at least one organ for most rnisadministration reports recolvod in 1990 and in commonly used radiopharmaceuticals is about 2 previous years. They also lists the number of rem, and a misadministration that results in any reports by type of misadministration, the number of organ dose of 2 tem is reportable. most of the patients, and the number of licensees reporting misadministrations continue to be reportable. misadministrations. The figure of 430 diagnostic misadministrations For 1981 through 1990, licensees reported 98 reported in 1990 was not significantly different from therapy misadministrations to the NRC, or an the average number reported in previous years, average of 10 therapy misadministrations per year. Over this period, 50 involved teletherapy, 30 involved brachytherapy, and 18 involved radiophar. As was noted earlier, relatively simple quality maceutical therapy. The primary causes for the assurance procedures, such as checking the teletherapy misadministrations were errors in dose patient's identification against the study and the calculations and misreading or misunderstanding pationt's saodical history, or asking the patient to thorapy prescriptions, orders, and patient charts-state his or her name, might reduce the frequency The primary causes of the brachytherapy of events involving administration of the wrong misadministrations were errors in dose calculation radiopharmaceutical or administering a proceduro and use of the wrong activity sources. The 16 r l to the wrong patient, radiopharmaceutical therapy misadministrations were primarliy caused by failure to assay dotes l before administering them or the use of the wrong form of the radiopharmaceutical. In general, the causes of all of the therapy misadministrations were NUREG 1272, Section 2 6

Nontoactors-Oporational Exporlonco l hunwn errors invdvrng dose calculations, pationt thoso,10 rnodical misadministration AOs occurnd sotuo or treatment, and patioht klontification. In NRC.rogulalod states ard two in Agrootnont States All of the nontoactor ovents dotortnintd to be AOs occurrod in NRC regulatext states. A The NRO recolved 443 reports of diagnostic misad. surnmary of 1990 nontoactor and modical misad. ministratk,ns in 1990. The number recolved annually ministration AOs (reported by both NRC aruf from 1981 through 1989 ranged from 334 to 437, Agroomont Stato licensoes) is provkiod in Apportlix with an average of 400 Most (94 porcont) C to this report A summary of 1930 AOs at nudoar diagnostic misadministrations involved the wrong power plants ard resoarch reactors is provklod in radiopharmaceutical (administration of a pharma. Apporxfh B to the companion volumo of this report coutical for the wrong study) or the wrong pationt, (NUREG 1272, Vol 5, No 1. Power Reactors), with the misadministrations stemming from hurrun error. 2.3 Completion of a Videotapo on " Good Practicos in Preparing in each of the 10 years from 1981 through 1990, a and Administering small number of diagnostic rnisadministrations Radiopharmaceuticals" Involvod the misadministration of lodino 131. An averago of 5 such events has boon reported annually; the rango is from 2 to 13 reports por year. in 1990, AEOD completod a vklootapo on Good A few of those misadministrations involv(d the administration of largo amounts of kdino 131. practicos in preparing ard administering radiophar. maceuticals. This videotapo used data from reported modical misadministrations to klontify The number of therapy events reportod during 1990 Hi so practicos that result in the most froquent was about throo timos the averago number reportod types d rnisadministrations in the previous 9 years, afd the number of diag-nostic reports orcoeded the previous 9-year The vkiootapo illustrates good practicos that ato avorage by about 10 porcent. Nonetholoss, the error designtd to avoki errors in preparing ard admin-rato for all typos of misadministrations romalnod istmng radiopharmacouticals The staff developed low. The estimated error rato rangod from 0.0002 the vkfoo with suppor1 from Oak Rkfgo Assoc:ated por procedure for brachythorapy ard radiopharma. Untvorsities ard Argonno National Lcboratories. coutical therapy to 0.0003 por patient for tolotherapy. Copics of the vklootapo have boon distributed to a!! NRC modicallicensees and regulatory agenclos for 2.2 Reporting of Abnormal Agroomont States. The information presented OccurrenCoS recognizes the commitment of the modical professional community arxl the NRC to good AEOD proparos the quarterly Abnormal Occurrence Report to Congress arxf the associated fodorat Rogistor noticos and, after staff coordination, sends 2.4 Selected Ongoing Technical them to Iho Exocutivo Diroctor for Operations (EDO) StudloS and, subsequently, to the Commission for review and approval. An abnormat occurrenco (AO) may be an indMdual incident, a recurring ovent, a AEOD is continuing work on the following technical - gonoric concom, or a serios of incidents that the studios: Commission determines is significant from the standpoint of public health or safety. Review of nonroactor events in Agrooment States, t990 in 1990. 20 medical misadministrations and 7 nonroactor ovents woro determined to be AOs Of 7 NUREG.1272 Section 2

i AEOD Annual Report 19CO Engineering Evaluation:

• Incidents involving a The staff will collect data on all events reported to Agrooment States for 1990, analyze the data, Hand Loading Brachytherapy Technique' and compare these events with events reportod (AEOD/N9141).

l In NRC heensed states. This review will provide a complete picture of the events that occurred { in all of the states. The AEOD staff will review events involving rnanu-l ally load (d brachytherapy devices in which patients recoNod unintended radiation dosos. ) f l i l i i r f i I i t l; i i l 4 NUREG-1272, Section 2 8

3 incident Investigation Program l The incident Investigation Program (IIP) onsures 3.1 incident Investigation of the that NRC Investigations of significant events are inadvortent Shipment of a timely, thorough, well coordinated, and fornwily Radiographic Source from administend. The scopo of the llP includes th Korea to Amersham investigation of significant operational events involving actMties licensod by the NRC. The primary Corporation, Burlington, objective of the llP is to ensure that operational Massachusotts. ovents ato investigated systomatically. All available information on the causes of the events, includir'g those involving the NRC's actMtles, is assomtWed On March 8, 1990, Amorsham Corporation, Appropriato information Icamod from the events is Burlington, Massachusetts, an NRC licensoo ptovidod to the NRC, the industry, and the putiic. authorized to manufacture ard distributo iridium 192 and cobalt-00 soahd sources for uso in 3rdustrial radk> graphy equipment, roceNod a Modol 500-SU The llP comprises two kirds of investigatory source changer from its Korcan product distributor, responso. For an event of potentially major signifi. Amersham porbonnel lator discovered that the cance, the EDO ostatAlshos an ll1. An llT is directed source changer contained a 2.4 curio, iridium 192 from headquarters and is composed of source capsulo in an unshiolded portion of the headquartes staff suppiomonted by regional staff. changer. Because the source changer was For an ovent of less significance. the cognliant NRC transported cross country by domestic motor Regional Administrator may establish an AIT that cantor, the potential oxistod for significant radiation consists of a regionally directed team comploment-exposure to a variety of indMduals ed by headquarters personnol and, in some casos, by personnel from other reglons, Of the approxl. mately 300 reported nonroactor events during 1990, On March 9, the EDO estatAishod an llT to perform one event, involving the Araersham Corporation in a comprehensivo review of the ovont and to Burlington, Massachusetts, was judged to have a determino the potential for exposure to those who sufficiently high levol of safety significanco to handled the source changer and to members of the warrant an llT investigation. One event was general putAic who camo in closo proximity to it. determined to be worthy of an AIT inspection. The team's report is documented as NUREG 1405. The findings and conclus!ons of the llT and AIT The significant firdings and conclusions from the reports are discussed in this section. The status of incident investigation included the following: staff actions that the EDO assigned to various NRC officos associated with the Amersham incident The cause of the incklont was a source that investigation is given in Appendix F. was inadvertently left in a source changer when the devico was n otumed from the ord user to Amersham's Korean distributor for shipment. Whdo potential radiation exposure to the general potile was possible, the number of 9 NUREG 1272. Section 3 _~

AEOD Annual Rrport,1D90 indkiduals exposed was limited because contan4 nation on a package when it is the shipment was maintained 'in-bord' from tocolved (10 CFR 20 205) and (2) licensoes hs arrival in Los Angeles on February 11, report incidents in which there is the 1990, until it clearod Unhed States Customs potential for significant exposure (10 CFR Service in Boston on March 7,1930. The 20.403). The incident boing investigated, in transport vehicle carrying the shipment which the source was recoNod in an from Los Angeles to Boston was driven unshioided position, was reported in across country with infrequent stops of accordance with the requirements of 10 mostly short duration. CFR 20.403. As an importer, Amersham was requirod to Cytogonotic studies performed on the five provide the shipper ard the forwarding irdNiduals who had the highest potential for agent, at the place of entry into the United exposure to radiation suggest that the States, complete information on how to source may have romalnod shioided so comply with DOT regulations. The that no actual exposures occurred until the instructions provided to the shipper by shipment was transferred from storage in Amersham for classifying and preparing the Boston to Amorsham's facility in Burlington, source changers for shipment were Massachusetts. Incompleto. Amersham did not provido " shipper" The safe handling and trensportation of radioactive materials iniported to the United instructions to the frolght forwardor at the States are highly dependent on the actions place of entry into the Unitod States (Los of foreign shippors and their agonts to Angeles) as requirod, but rather to its properiy prepare packages for shipment, customs broker in Boston. In this case, proporiy identify the contents, and Amersham provided an erroneous accurately describe the contents in instruction to transport the package as an shipping documents. Neither the ' excepted" package. Department of Transportation (DOT) nor the NRC requires that carriors or shipping Amersham's instructions for returning an agents monitor or survey shipmonts during transit. empty Model 500 SU source changer were made available to NDI Corporatior' a'M Korean industrial Testing Company e Carriers, freight forwarders, or shipping were adequate for determining whether a agents at the United States place of entry source changer contained an uncropped do not verify indeperdently the accuracy of source. However, the instructions were shipping documents for import shipments. deficient in that they dio not snticipate that Current DOT regulations require carriers to sources without pigtails might be stored in report incidents that involve death, serlous the source changer and not removed injury, substantial property damage, before shipment. breakage, spillage, or suspected radioactive contamination. NRC regulations require that (1) licensoos report any instance in which The team found no violation of NRC there is sign'.ficant reduction in the regulations with respect to the receipt of l offectiveness during use of any NRC-the source changer shipment at l authorized packaging (10 CFR 71.95) If Amersham. l there is a high radiation level or i NUREG 1272, Section 3 10 l i

l Nontoactors-incktont invo:tigation Program DOT regulations permit the use of an NRC-for uranium in water. On August 23,1990, Roglon IV cortified Type B package, such as the sont an NRC inspector to the site to review the Moriol 500 SU source changer, for report. Because of the apparent lack of awareness shipment of a Type A quantity, for example, by SFC of the potantial significance of the elevated either as empty (with the depleted uranium concentrations, Region IV dispatched a four-person shielding) or with a source totaling loss AIT to the site on AugJst 7,1900, to (1) review the than 20 curies. However, DOT rogulations circumstancos surrounding the contamination found are ambiguous as to whether an NRC-in the excavation near the SX building, (2) evaluate cortiflod Type B package must be usod in the licensee's actions, and (3) determino, to the strict accordance with the NRC certificate extent possible, the impact of this event on the for shipment of Type A quantitles or health and safety of the workers and the public in whether the package nood only comply general. with the general requirements for Type A packages in DOT regulations. Thus, the team could not dotormino whether the Some of the significant findings arvi conclusions of source involve 3 in this incident could have the AIT included the following: boon shinpod in the Model 500 SU source During the excavation for the vault around changer as a Type A quantity because the source (with or without the pigtall) is not the hexane tanks noar the SX building, authorized in the NRC certificate. uranium <ontaminated waters and uranium salts wore discovered in the pit. Measurements of water samplos showod The 14 source changers involved in the uranlum levels as high as 8.1 grams per incident did not conform to the drawings liter. Uranium <ontaminated water also referenced iri the applicablo NRC Certificate existed in the aggregate fill under and in of Compilance. These discrepancies did not the vicinity of the SX building. Some of this contribute to the cause of this incident. water will probably remain relatively immobile. The roiaainder is probably moving at a very slow rate toward the 3.2 Augmented inspection Team North Ditch or tho sewage lagoon. Inspection of Water Contaminated with High Initial investigations of ground water in the Concentrations of Uranium vicinity of the SX building indicate that Discovered During Excavation contamination apparently has not migrated Work at the Sequoyah Fuels off the sito and had not come in contact Corporation's Facility, Gore, with any aqulfors that may be used by the Oklahoma public. The sources of the contamination were On August 22,1990, Sequoyah Fuels Corporation (SFC) in Gore, Oklahoma, reported to NRC Region apparently solutions that had soepod over IV that uranium-contaminated water had been the years through the floor of the SX discovered seeping into an excavation near the building. leakage from the old evaporator solvent extraction (SX) building. The uranium pad that was located adjacent to the SX concentration in the seepage varied but was as high building, and overflow from the solvent as 8 grams por liter, substantially above SFC's dump tank. These sources have been eliminated. environmental action level of 0=000225 gram per liter 11 NUREG-1272, Section 3 l l

_ _ ~. . -. = AEOD Annual Report,1990 During September 10 through 13, 1990, the AIT oxtraction process. The inspectors dolorminod that inspected SFC and reviewod both the findings of the licensoo's actions satisfied the commitments, the AIT and the actions the licensoo committed to and on September 13, 1990, the NRC gave the in an August 30, 1990, letter to the NRC. The licensoo its concurrence to restart tho solvent actions woro proroquisitos for restart of the solvont extraction process. l NUREG 1272, Section 3 12 L.__--._._..,,,,_:..__ -.. ~

- - - - _ _ _. - - _ _. - _ _ _. _ _ _ - - - _ _. - _ ~.. _ - -. _ _ _ - - _. _ - _ _ _ _.. _ - - 4 Summary The AEOD review of the data on nontoactor events Section 3. The number of diagnostic misadministra-that woro reported to the NrtC in 1990 dki not show tions eoportod in 1100 was about to percent greator any significant changes from the data reported to than tho average number reported annually in the the NRC in previous years, An Ili was assembitd to provious 9 years,1981 through 1989. The number investigato one event, and an AIT was formod in of therapy misadministrations reported in 1990 was response to another event as discussed in about throo timos the average number reported annually in the previous 9 years,1981 through 1909. l i I l l l l i 13 NUREG 1272, Section 4

Appendix A Report on 1990 Nonreactor Events

I l Appendix A AEOD/N9102 Report on 1990 Nonreactor Events by the Nonroactor Assessment Staff Offico for Analysis and Evaluation of Operational Data ~ Preparod by Kathleen M. Black

Table of Contents 1 Nonreactor Evont Roport Databaso A.1 2 Review of 1990 Nonroactor Evonts A-3 2.1 Events that Occurred during 1990 A-3 2 1.1 Radiation Exposure....... A-4 2.1.2 Lost, Abandoned. and Stolen Sourcos. A7 2.1.3 Leaking or Contaminated Sourcos A 11 2.1.4 Roloaso of Materials..... A.12 2.1.5 Consumor Products...... A 12 2.1.6 Fuol Cyclo Faciuties.. A 12 2.1.7 Radiography........................ A.13 2.1.0 Manufacturing and Distribution.. A 14 2.1.9 Gaugos arvj Measuring Systems A 16 2.2 Abnormal Occurrences... A-10 3 Findings........... A-19 Tables 1 Tys of liconsoos : hat submittod nonroactor reports during 1990 A-3 2 Categ'vlWbn :)f reports of nonroactor events that woro repor1od during 1990 A4 3 f orson%1 radiation exposures.1990.. A-5 4 Lost or stolen sourcos,1990 A9 G Abandoned well logging sources.................................. A-11 Leaking sourcos,1990. A-12 7 Radiography events,1990. A-14 8 Manufacturing and distribution,1990.. A 15 9 Gaugo I, and measuring systems,1990..... A 17 A-lii NUREG 1272. Appendtx A _~

l 1 Nonreactor Event Report Database The Nonreactor Event Report (NRER) datatuso for events into the NRER database because the the Office for Analysis and Evaluation of Department of Energy funds a transpor*ation Operational Data (AEOD) contains information on incident fde, which is maintained by Sandia l',v.*p.< 1 clear materials and fuel cycle operational National Laboratories The Sandia report 9 M t m t : ' personnel radiation exposure events. Transportation Accidents /locidents Involving itP.UA & rQase management system provides Radioa ctive Ma terials 1977 1989 (S AND-90 -7025C) *

O f, 'N;.. - h W, ', retrieval, and computer assisted summarizes data from 1971 through 1909.

s

F (n. - g cy ational event data; the system may be w%l 'd dent % trerds in operational safety f

w ytteu mn.t,.em,ta#An w en:uemamunsuwaaw events that may signal a need for remedial actions y,....., 4 7 3, m. num, m,c, < n c wn, 4,o n,o by the NRC, licensees, or both. AEOG generally does not incorporate information on transportation A1 NUREG-1272, Appendix A

i 2 Review of 1990 Nonroactor Events 2.1 Events That Occurred During 1990 documents, primarily in reports of inspections conducted by NRC. The NRER database does not include information from certain fuel cycle licensee The NRER database includes 309 records of events reports, such as those related to routine effluent that were entered into the database during 1990. releases, nor does it include information from This number is equivalent to approximately 6 reports of medical misadministrations, which are reports per 100 licensees. Information on these included in Appendix B to this volume of the AEOD events was included in reports submitted by non. Annual Report. Table 1 providas information on the reactor licensees to the regional offices or in other types of licensees for which information was entered into the dataase Table 1 Types of licensees that submitted nonreactor reports during 1990 Type of Licensees No. of Reports Received

• Academic 13 Medical 61 Commercial and indu;, trial measuring systems 67 Well logging,

22 Other measuring systems 45 Manufacturing and distribution (excluding medica!) 13 Industrial radiography 11 Fixed site o Multiple locations (field). 11 Irradiator 6 Research and development 26 Source materials" 14 Mills 1 UF facilities. 1; e Other 2 Special nuclear material" (including plutonium) 18 Agreement State. 42 Other 33 Total 309

• Med* cal trusaderwstf ation repyts eve not incivoec "houtne ensranmentai ethnt feirate repnrts se g, repert3 reasred t.y 10 CF R 40 f>5 and 10 CF k 70 M,i were not inctukd in the 1013;$ hY BDurte Fr.atergg ed special rgy tear material hce%ces A-3 NUREG-1272, Appendix A

AEOD Annual Report,1990 Table 2 provides information on how the reports for exposure events as well 6s 10 tha total numbo: of nonreactor events were categorized and entered events involving radiography. The 309 nonreactor into the database. An NRER database record may licensee reports were cataloged as 367 entries in 9 be associated with more than one category of different areas. Note that because some reports are event. For example, a report from a radiography associated with more than one category of event, licensee concerning a personnel radiation exposure the total number of events exceeds the total number 4 would be counted in the total number of radiation of reports. l Table 2 Categorization of reports of nonreactor events that were reported during 1990 No. of Category Associated Reports' Personnel radiation exposures. 34 Lost, abandoned, and stolen material . 132 Leaking sources. 14 Release of rnatorial.. 35 Fuel cycle (e g., mills, source material, UF, facilities, special nuclear material) 30 Industrial radiography 11 Manufacturing and distribution (including medical) 13 i Commercial and industrial measuring systems 1 (excluding well logging) 34 Other*

• 44 Total.

. 367

• An NRER database record may te assocated wfth more than one category of event. Fc,r euampio, a report from a ra$ography bcensee concerrung a personriel f a$ation esposure would be counted 61 the total nu nber of ra$atgm exposure event 6 #s well as r

in the total numt.er of events innMog ra$ography.

• • "Other" includes categories such as me$ cal. transportat:on, aM fmscellaneous.

2.1.1 Radiation Exposure Restricted areas: The criteria that define overexposures are contained whole body 1.25 rem /calenda; quarter, or 3 in 10 CFR 20.101(a) and (b),20.103a. and 20.105. rem / calendar quarter, if the indM. l-The limits that were in effect during 1990 are as dual's prior occupational exposure l follows: is obtained in writing, and the accumulated exposure does not l-exceed 5 (N 18), where N is the

• As 10 CF R Fart 20 was reeed in 1M1. these teveis may no Weger t,e Individual's age.

amicame. NUREG-1272, Appendix A A-4

Nonteactors-Events cattemity 18.75 rem /catendar quarter Unrestricted areas: skin 7.5 rem /ca!endar quarter individuals 0.5 rem / year, subject to rate limi-tations Inhalation 40 MPC hours / week for 13 weeks; MPC (maximum permissible con-The NRC received 34 reports of events during 1990 centration) is given in 10 CFR Part in which there was the potential for or an actual 20, Appendix B, Table I, Col.1 radiation overexposure. Of the 34 events, 24 involved actual overexposures Thirty individuals recolved expocures in excess of ona of the minors 10% of above limits regulatory limits discussed above. Information on the exposure reports is provided in Table 3. Table 3 Personnel radiation exposures,1990 Licensee License Location Event N o. Type of Date Exp. Exposure Allegheny General Hospital 370131701 Pittsburgh, PA 07/01/89 2 Whole Eady Alt & Witzig Engineering, Inc 131868501 Indianapolis, IN 11/01/88 1 Whde Body AS Duke Univer. Med. Ctr. AS Durham, NC 04/16/88 1 Internal AS Rosemount AS Mt Pleasant, IL 07/11/90 1 Extremity AS Ultrasonics Field Ser. AS Carson, CA 06/15/90 1 Whole Body Barnett Industrial X-Ray 352695301 Ardmore, OK 04/06/90 2 Whole Body Consolidated NDE, Inc. 292145201 Woodbridge, NJ 07/01/88 3 Whole Body Diagnostic Photon Corp. 521634502 Carolina, PH 06/01/90 1 Whole Body General Electric Co. Wilmington, NC 06/11/90 3 Extremity Ind. Dept. of Transportation 130968901 W Lafayette, IN 07/01/89 1 Whole Body industrial NDT Services 130614701 Indianapolis, IN 09/12/90 1 Extrernity LFE Industrial Systems Corp 200138202 Clinton, MA 02/01/89 1 Whole Body Lucy Lee Hospital 201665201 Poplar Bluffs, MO 11/28/90 1 Whole Body Medical Center of Delaware 071216302 Newark, DE 04/25/89 1 Whole Body Mercy Hospital 370137403 Scranton, PA 02/15/90 1 Whole Body Midwest inspection Services 481616296 OH 12/18/89 1 Whole Body Monongahela Valley Hosp. 370657503 Monongahela, PA 02/28/90 1 Whole Body MOS Inspection, Inc. 120062207 Elk Grove, IL 02/21/90 1 Whole Body Radidogy Ultrasound Nuc. 290676007 Freehold, NJ 12/09/86 1 Whde Body Sigma Chemical Company 241627201 St Louis, MO 02/14/90 1 Whole Body St Louis Testing Lab. 240018802 St Louis, MO 08/23/90 1 Whole Body Tri State Associates, Inc. 452496701 Woodbridge, VA 05/28/90 1 Whole Body Tumblewood X-Ray Co. 032318501 Greenwood, AR 11/26/90 1 Extremity Western Stress, Inc. 422690001 Bordentown, NJ 10/05/90 1 Extremity A5 NUREG 1272. Appendix A

AEOD Annual Report,1990 The types of licensees associated with the '4 excess of 15 rem, ard the assista ' also receked i overexposures follow several thousand rem to his neck. No. of in the second AO, a radiographer employed by Type of No. of Individuals Western Stress receNed a hand exposure in excess Licensee Reports OmW of 1000 rem when he grabbod a source guide tube containing the source. academic 7 8 Radiography 9 12 h h M Q m m% d hWW LRy U** * 'C 8" recolved a doso of several thousarx.! rem to h;s us W 4 4 hand tha; resulted in skin blistering. Fuel Cycle 1 3 Agreement State 3 3 in another event, an employee of Industrial NDT Services received an extremity dose of up to 100 rem to his hand when he grabbed a source guide tube to steady the radiography device when the Medical and Academic source was not fully retracted. In the remaining 5 events, employees of radiographers roccived doses in excess of the quarterly limit. No specific reasons The seven reports from seven medical and were given for the exposures. academic licensees represent overexposures of eight employees in the course of their work. One report concerns the exposure of an individual of 8.7 Commercial and industrial tem in one quarter. The other reports list individuals who received more than 1.5 rem in a quarter. None of the latter indMduals roccived more than 2.0 rem in one event, a licensee reported that an employee in a quarter. had received a whole-body dose of 3.7 rem when an explosion sprayed liquid containing carbon-14 on his arm; the carbon-14 was absorbed through the Radiography skin. The other events involving employees of commercial and _irdustrial licensees were occu-pational exposures that exceeded the limit of 1.25 Nine radiography licensees reported exposures of or 3 rem per quarter. 12 employees received as the result of their employment. Fuel Cycle in three events, four ind:viduals received doses that were high enough for the events to be considered Three employees of General Electric receNed to be Abnormal Occurrences (AOs). In the first AO, occupational exposures to the extremeties that two employees of Barnett industrhi X Ray were exceeded the quarterly allowable limit of 18.75 rem. exposed when the source became disconnected. One of the individuals draped a guide tube containing the source around his neck. Both employees received whole-body exposures in NUREG 1272, Appendix A A-6

Nonroactors-Events Agrooment State Uconseos Carbon 14 (C 14)---Three ovents involved materials containing carbon-14 tint were inadvertently disposed of as trash. In a fourth event, a packago Of the three events reported from Agreement containing carbon 14 was tost en touto to Europe. States, two concemed occupational exposures that excoodod tho quarterly limits, in the third event, a graduate student ingested phosphorus 32. Cosium-137 (Cs 137) -Ton of the 11 reported lost cosium 137 sources were scalod sources. Four hospitals reported losing sources ranging in contont 2.1.2 Lost, Abandoned, and Stolen from 0 5 to 53 rnillicuries. One licenseo reported the loss of a cosium 137 source from a moisturo density SOUTCOS gauge. Four sources woro lost in gaugos; the isotopic content ranged from 12 to 100 millicuries. Nucor Steel, an Agreement State licensee, reported Licensees are required to report the loss or theft of discovering coslum 137 activity in flue dust; an licensed sources that has occurred in such incoming gauge had inadvertently been molted with quantitles and under such circumstances that it the steel appears to the licensee that a substantial hazard may result to persons in unrestricted areas (10 CFR 20.402(a)(1)). During 1990, 132 ovents were Tritium-3 (H-3)-Four of the 7 reports of lost tritium I reported that involved lost, abandonod, or stolen sources concerned lost trKlum-containing com-licensed material. Tables 4 and 5 provide summa, pounds. Two licensees toported the theft of tritium rios of events in which the material was not ed signs or runway tights. One report concernod a recovered. Of these events,114 involved lost or lost conapass stolen material and 18 involved abandonod, irretrievable well-lagging sources. None of the events resulted in a known radiation overexposure. lodino-Eleven reports were of lost lodino iso-topes-either lodine 125 (1-125) or lodino-131 (I-131). The lost iodino 125 consisted mainly of soods; Lost or Stolen Sources the lost lodine-131 consistod mostly of contaminated materials that were inadvertently mixed wkh ordinary trash. Of the 114 reports of lost or stolen sources, 29 sources were found, 23 sources were sent to commercial wasto disposal,6 were sont to scrap Nickel 43 (nib 3)-The lost nickel 43 sources were processors,3 were incinerated, and the location of all components of instruments that were lost with 49 is unknown In addition, another four have been the instrument. One source was lost in transit, the disposed of in other ways. Table 4 presents a list of other three were sont to landfills or to a scrap theso events. Generally the lasi curces consisted dealer. of sealod sources, isotopes esed n research or medical treatment, or tritium exn clar.l. Phosphorus 32 (Pa2)-The lost phosphorus-32 was generally inadvertently disposed of as trash, Americium-241 (Am 241)-Of the 12 reports of lost although one report descriLad a package of americium sources,11 involved stolen moisture phosphorus 32 missing in transport. density gauges that have not been reported as recovered. The twelfth report concerned a stolen mineral analyzer. A7 NUREG-1272, Appendix A

AEOD Annual Report,1990 Promethium-147 (Pm-147)-The lost promethium-Strontium 90 (Sr 90)-Strontium-90 was lost in a 147 sources were all contained in gauges or other

gauge, devices.

Thorium (Th)--The two losses of thorium involved Polonium-210 (Po-210)-The lost sources con-a lost check source and the discovery of thorium-talning polonium-210 were all contained in static contaminated scrap. eliminator devices that were lost. Uranium (U) (depleted)---The depleted uranium Plutonium-238 (Pu 238)-A plutonium-power was lost in aircraft counterweights and in a missile. pacemaker was reported lost. Other and unspecified materials-Of the three Sulfur.35 (S-35)-One of the lost sulfur-35 events events in which the isotope was not specified, one involved a misplaced package; the other involved involved a missing air gun and two involved contaminated waste that was inads ertently disposed contaminated trash that was inadvertently disposed of with ordinary trash. of with ordinary trash. NUREG 1272, Appendix A A-e

ummmmmmm_ _ Nonteactors-Events 1 l Table 4 Lost or stolen sources,1990 hoteu6e Ucense Event litsrate bolopi locaton Lkentee Nuenter" Date Dispor.al Am 241 Tucson, AZ AS Argona nua Mines AS 01/28/90 Unk nown Am.241 Cullman, AL AS Ala H'ghway Depart AS 02/15/90 Unknown Am-241 Anaheim, CA AS Moore & Laper Inc. AS 03/10/90 Unknown Am-241 Cyprus, CA AS Pac 4hc Sods & Eng AS 04/22/90 Unknown Am-241 Miami, FL AS Dept. of Trans Ronda AS 10/04/'A Unk nown Am-241 Hollywood, FL AS Post, Buckley, Shu and Jer. AS 10/01/90 Unknown Am-241 Chicago, IL AS GME Consultants AS 12/18/90 Unknown Am-241 Westerville, OH Resource international 341853201 06/07/90 Unknown Am-241 Enon, OH West Env. & Geotech 32211B301 11/29/90 Unknown Am-241 San Juan, PR Jaca, Sierra and Rivera 521M)6401 12/18/89 Unknown Am-241 Wauk esha, WI Greenfield Engineenng 481854701 10/31/90 Unknown Am 241 St Ann MO McClelland Consultants 242453901 07/05/90 Unknown Au-195 St. Paul, MN United Hospitals. Int 220191402 06/22/90 Unknown C-14 Uniroyal Oro022108 04/04/90 Comm Waste C-14 Washington, DC Children's Nat Med. Ctr. 080330901 01/15/90 Comm. Waste C 14 Washington, DC Georgetown Univ. Med Ctr. 080170904 07/15/88 Comm. Waste C 14 Midland, Mt Dow Chemical Company 210026506 05/30/90 Unknown Cd 109 Wayne, PA Sun Pipe Une Company GL 10/22/90 Unknown Co fiO Meriden, CT Canberra /Metpath New Eng 061509901 06/14/90 Unk nown Co44) Scranton, PA Univoroty of Scranton 370423703 10/15/87 Unknown Cs 137 Le Boc CA AS Nat'l Cement Go CA AS 03/22/90 Comm. Waste Co 137 Miami, FL AS Pan American Hospital AS 01/05/90 Unknown Co 137 Orlando, FL AS Florida Hospital AS 01/03/90 Unknown Co-137 South Bend, IN Michiana Cornm. Hosp. 130c65201 09/20/90 Unknown Cs-137 Wheaton, MD CTI, Inc. 452363101 05/31/90 Unknown Cs-137 Saginaw, Mt General Motors Corp 210867803 05/12/90 Scrap Co-137 Laurel, MS AS Masonate Corporation AS 12/19/89 Unknown Cs 137 Hoboken, NJ GL General Foods %fp. GL 08/15/90 Unknown Co-137 Newburg. OR GL Smurfit Newspont Corp GL 04/09/90 Scrap Cs-137 Philadelphia, PA Thovas Jef+erson Univ 370014FO6 12/14/89 Comm. Waste Co-137 Plymouth, UT AS Nucor Steel AS 02/26/90 Scrap H3 Fairbanks, AK Gu Alaska Dept. of Trans GL 03/12/90 Unknown H-3 Maxwell FD., AL Dept. of Aar Force 422353901 12/27/89 Unknown H-3 Milford, CT GL Red Roof inn GL 01/l3/90 Unknown H-3 lowa City, LA Vet Admin Med Ctr. 140082201 12/14/90 Unknown H3 Deltsville, MD Dept. of Agoculture 190091501 07/19/90 Unknown H-3 Oklahoma, OK Ok. Med Ret Found. 35074CA03 07/19/90 Unknown H-3 Milwaukee, W1 Mdwaukoe Cty. Modcomplex 480419301 03/30/90 Unkncwn roctnctes et end of teie A-9 NUREG 1272, Appendix A

AEOD Annual Report,1990 Table 4 8.ost or stolen sources,1990 (cont.) probable Umnas Event (Atimate buiup/ ! ~*w Ucensee Nunamtr" Date Dspnal l Charleston, SC Vet Admin Med Center 391213002 01/0F/90 incinerated F125 Arlington Hts, IL Amersham Corporation 1212fL%C2 01/29/90 Jnknown F125 Oncinna*i, OH Menell C% Pharmaceuticals 340364301 03/27/90 Unknown L125 Columbus, OH Ohio State Univeisity 340029302 10/11/90 Comm. Waste L125 Philadelphia, PA Temple University Hospital 3700R9702 12/27/89 incinerated 0125 Richmond, VA Stuart Circle Hospital 451833201 10/01/90 Unknown F131 Manchester, CT Mai,chester Memorial Hosp. 060341301 06/21/90 Comm. Waste F131 Newark, DE Medical Center of Delaware 071216302 04/25/89 Comm. Waste 1-131 Fbyal Oak, Mt Beaumont Hospital 210313301 05/26/90 Comm. Waste L131 Mn Arbor, M1 University of Michigan 210021504 03/12/90 Comm Waste I131 Toledo, OH Toledo Hospital 340171005 06/26/90 inc.n. k192 Muskogee, OK Muskogee Reg. Med Cea 331315701 10/31/90 Unknown Kr85 Lynn, MA Phillips Ughting Company 292000902 05/18/90 Comm. Waste Kr45 Battle Creek, Mi Dept. of Ar Force 422353901 08/24/89 Unknown t 85 Pottsville, PA Allied Signal, Inc. 371692401 10/12/90 Scrap .r-85 Offshore, TX Dept. of Air Force 422353901 07/06/90 Ocean

r.65 Weston, WV NL N. Amer. Phillips NL 05/02/90 Unknown Ma-99 Panama Oty, CZ NL Eastern Airlines NL 12/29/89 Abandoned Ni 63 New Orleans, LA Dept. of Airry 171675302 09/22/89 Sorap Ni6J Cambodge, MA Erco/Enseco 07/15/90 Comm. Waste Ni-63 Kansas City, MO Missouri-Kansas Oty, City of 241138801 05/08/90 Comm. Waste Ni-63 Amherst, NY AS Ber,ra E.,vironmental Inc. AS 04/03/90 Unknown P-32 lowa Oty, IA Vet Admin Med. Center 140082201 04/11/89 Comm. Waste P 32 M,nneapolis, MN University of Minnesota 220018746 02/21/90 Comm, Waste P 32 Princeton, NJ Princeton Umvenuty 290518424 09/07/90 Unknown P-32 Newark, NJ Rutgers University 290521828 06/09/89 Comm. Waste Pm-14 T Andover, MA Digital Equipment Company 202081501 10/25/90 Unknown Pm-147 Fort Bragg NC Dept. of Army 120072207 05/01/90 Improper Disposal Pm 147 Plover, W1 GL Det Mor te GL 07/16/90 Comm. Waste Po-213 Clemens, M1 GL Uonel GL 04/27/90 Unknown Po-210 Marysville, M1 GL Marysville Plastics Corp GL 07/15/89 Unknown Po-210 Holland, M1 GL Prestige Vacuum Printag GL t?/01/80 Comm. Waste Po-210 St Paul, MN GL Unisys Corp 220774201 11/12/90 Unknown Po-210 Marion, VA GL D G, Molegs GL 04/04/90 Unknown Pu-238 Wichita, KS AS HCA Wes

ey Med. Center AS 01/23/90 Unknown S-35 Ann Arbor, MI University of Michigan 210021504 09/13/90 Unknown S-35 Develand, OH Case Westem Reserva Univ. 340073604 10/15/90 Comm. Waste St-90 Spnngfield, MO Swootheart Cup 2 242446201 11/15/86 Unknown Th Bridgeville, PA NL Cytemp Spec Steel Co NL 12/15/89 Scrap Th-230 McChord, WA Dept. of ht Force 422353901 12/05/89 Unknown U depleted San Antonio, TX Dept. of At Force 422353901 04/26/9C Buried U depleted Dugway,UT Dept. of At Force 422353901 04/27/90 Unknown Z

Burt Ridge, IL GL Federal Sign GL Unknown 2 Muskegon, M1 MuskeDon General Hospita! 211797101 09/24/90 Comm. Was te Z Newark, OH Ucking Memorial Hospital 341701301 02/26/90 Comm. Weste 2 Hampton, VA Vet Admin Med Center 450756901 04/19/90 Comm. Waste 2 Abonito, PR Mennonite General Hospital 5?2505801 02/06/90 Comm. Waste

• 2 unspetDed

" AS A;;reement State licensee GL generalPense N,. AO liCPD$e NUREG-1272, Appencix A A-10

Nonroactors-Evznts Abandoned WelkloaL;no Sources 18 events reported during 1990 did not result in any known roloases of radioactive materials. (See Table 5.) NRC licensoes are required to report the location of abandoned woll logging sources to NRC. The Table o Abandoned well-logging sources Doenae Event bootope Locatum Woonsee Number Date Am-241* Halliburton Co. 420190842 01/05/90 Am-241 Ortshore Halliburton Co. 420196842 04/06/90 Am-241 Offshore Haliiburton Co. 420190642 05/06/90 Am-241 Offshore, LA Anadrill Inc. 422087701 01/18/90 Am.241 Offshore LA Anadrill inc 422667701 04/23/90 Am-241 Offs %re, La Anadrill inc 422687701 05/21/90 Am-241 Offshore, LA Western Atlas Intemational d20296401 11/30/90 Am-241 Offshore, LA Sperry Sun Driihng Services 422684401 12/29/89 Am-241 Offshore, LA Sperry-Sun Drillin9 Services 4J684401 01/27/90 Am 241 Offshore, LA Sperry-Sun Drilling Services 422684401 02/02/90 Am-241 Offshore, LA Sperry-Sun Drlikng Services 422684 01 03/01/90 Am-241 Houston, T X Schlumberger Well Services 4.!a009G'3 04/18/90 Cs-137 Offshore, LA Western Atlas intomational 420296401 05/01/90 Cs 137 Gr een Twp., PA ADegheny Nuclear Surveyo 471197601 c3/23/90 H-3 O' c>re Western Alias international 42c296401 12/10/90 H-3 Offshore Compulog Wireline Serv., Inc. 422689101 07/17/90 M Houston, TX Schlumberger Weli Services 420009003 12/27/d9 U Offshore, LA Halliburton Co. 350050204 09/12/89

• In most casen, when en amertetum source is scandoned, a Cs-137 source la aino abandoned.

2.1.3 Leaking or Contaminated Sources 10 CFR 34.25 or a licenso condition must be reported to the NRC. Some licensees are required to leak 4est sources Fourteen occurrences of leaking or contaminated and to report leaking ones under 10 CFP '4.25; sources Were reported during 1990. Table 6 includes information from reports of these events. others are required to leak test sourc:s o a None of tho events resulted in a radiation report leaking ones as a condition of their license. in both cases, a removable contamination overexposure. The isotopic sources found to be l exceeding the most common test limit for leaking or contaminated contained americium, i removable contamination (0.005 microcurie) is curium, ceslum, tritium, krypton, nickol, and considered-evidence of leakage. Removable strontium, contamination exceeding the amount specified in A-11 NUREG 1272, Appendix A

AEOD Annual Report,1!F30 m i Table 6 Leaking sources,1990 Lkanse Event Manuixturer botope locaton Licensee Numter Date Am 241 New Drighton MN 3M Company 22T05706 03/ts/W) Am-241 Twinsburg. OH GE Reuter Stokes 341823301 08/29/90 Monsanto 2705 Cm-244 Philadelphia. PA Temple University 370069731 11/03/89 lso Pdt Labs Afr 244 Cs 137 Toledo, OH Victoreen. inc. 342595901 08/21/90 Ana sham SN124 H-3 Picatinny, NJ Dept of Army 290004706 11/01/89 Kr85 N. Andover, MA AT&T Network Systems 20G352701 11/08/90 N;43 NL (Hewlett Packard Co ) NL 08/23/90 Hewlett Packard Ni43 Boston, MA B+o Tec Inc. 202074501 12/05/89 Perkin Elmer Ni-C,3 St Paul, MN 3M Company 220005707 02/09/90 Perkin Elmer Ni43 St Louis, MO Dept of Hea!th 240975%2 01/24/90 Hewlett Packard & Human Services Ni43 Pnntaton, NJ Mobii Oil Company 291409701 12/18/90 Hewlett Packard Ni43 west Point, PA Merck Sharp & Dohme 370153108 06/a/90 Varian T-497 Sr 90 St Louis, MO Washington Unw. Med Ctr. 240016711 06/19/90 Amersham Z* iwrwalk, CT Perkin Elmet Corporation 060213508 06,f22M)0 Nuclear Radiation Corp

• / rned% urmt edfmd 2.1.4 Release of Materials 2.1.6 Fuel Cycie Facilities During 1990, 35 events were reported in which The NRC enterni information on 30 fuel cycle radioactive materials were released. Generally, the events ino the nonreactor database in 1990. Of events had little effect on any area beyond the these events I concerned milling.11 concemed the immediate area of the release. The most significant manufacture of uranium hexafluoride, and 18 event involved the discovery of water that contained concerned fuel fabrication.

high concentrations of natural uranium at Sequoyah Fuels Corporation. This event is discussed further in Section 3 of this volume and Section 2.1.6 of this Manufacturing Events appendix. AD" i Signal, Metropolis, Illinois, reported three 2.1.5 Consumer Products One event concemed a chemical reaction nurred in a primary cold trap; the reaction c! n si result in any releases The other events An additional categorv of event, ' consumer c'cerned small releases of uranium hexafluoride products," was defined and included in the database (UF,). The first release was from a sampling line. e in 1985. Reports of this category of event describe The second release occurred when operators were those events in which radioactive r"aterial was attempting to dislodge a restriction resulting from found !n, or had a reasonable probability of being solid!!ication of uranium compounds. Introduced into, nonlicensed consumer products. NRC received no reports of this type during 1990. Sequoyah Fuels, Gore. Oloahoma, reported eight events to the NRC in 1990. The most serious event was the discovery of uranium contaminated water in an excavation near a processing building This NUREG 1272, Appendix A A-12 a

._.~.- i Nonreactors-Events 1 event was the subject of an augmented team the second report was of the explosion of a pump inspection. Four events involved releases - a spill that resulted in some release of solution to the l of 14,000 pounds of depleted UF, a release of environs of the _ pump, The two other reports 4 - about 100 grams of depleted uranium as UFe, a concerned lighting damage to the criticality waming leaking drum, and a release of 100 pounds of uranyl system and an individual who left the site with 4 nitrate solution. The other three events concemed contamination on his feet. An improper frisk was excessive rainfall, unnecessary activation of a fire citeo as the cause of the last event. suppression system, and a spill of 1500 gallons of nitrogen fertilizer as the result of a vehicle accident. Nuclear Fuels Services, Erwla, Tennessee, reported Uranium fuel Cycle Events three events, in the first event, uranium solutions exceeded the criticality control limit. In the second, a cnticality control limit was exceeded when a Advanced Nuclear Fuels Systems, Richland, uranium solution with a concentration that exceeded Washington, reported an event in which a qualified the administrative limit was transferred to a wasto health physics technician left the facility with tank. This latter event was the subject of a special contamination on his shoe. inspection. The NRC found that this event was attributable to the piping layout, operator training, and the absence of design documentation and - Babcock and Wilcox, Lynchburg, Virginia, reported drawings. A third event concerned the discovety of three events. One event concerned transportation, contaminated sludge in an old, seldom used the s6cond concerned a fire in the laundry, and the digester at the City of Erwin waste treatmerit plant. third event concemed the cleaning of ducts that contained enriched uranium without a critica!4y UNC Naval Products, Connecticut reported that the review. uranium-235 content of an unknown number of drums in an array was not measured and could be high. Combustion Engineering, Windsor, Connecticut reported three events. Two involved criticality control violations and the third event was an Westinghouse, Columbia, South Carolina reported outdoor fire that did not breach the inner wall of the a fire in a decontamination room. Radioactive contaminated area of the facility and did not involve materials were not involved. radioactive materials. Combustion Engineering's Missouri facility reported two other events. One event concerned buming of the liner in the 2.1,7 Radiography incinerator recirculation system; no relear,es occurred. The other event involved a small uranium hexafluoride leak, which occurred when a sample During 1990,11 events were reported that involved tube was pulled off before the samp!e valve was radiography. All of these occurred at remote sites. ful!y closed. Table 7 provides information on these reported events. All of the events concerned overexposures or potential overexposures and one event also in-General Electric, Wilmington, North Carolina, volved contamination of a piece of radiography reported four events. The first report was a fire in equipment. the containment ventilation of a slugger press and A-13 NUREG 1272, Appendix A

AEOD Annual Report,1990 Table 7 Radiography events,1990 Iso-License Event Type of tope Location Licensee Number Date Event tr-192 Greenwood, AR Tumblewood X-Ray Co. 032318501 11/26/90 Exposure Ir-192 Elk Grove, IL MOS inspection, Inc. 120062207 02/21/90 Exposure Ir-192 Indianapolis, IN Industrial NDT Services 130614701 09/12/90 Exposure Ir-192 Bordentown, NJ Western Stress. Inc. 422690001 10/05/90 Exposure Ir 192 Ardmore, OK Barnett industrial X Ray 352695301 04/06/90 Exposure ir-192 N. Charleston, SC industrial NDT Company Inc. 392488801 04/02/90 Exposure Ir-192 Woodbridge, VA Tri State Associates, Inc. 452496901 02/01/90 Exposure Ir-192 Woodbridge, VA Tri-State Associates. Inc. 452496701 05/28/90 Exposure Z' St. Louis, MO St Louis Testing Lab. 240018802 08/23/90 Exposure Z Woodbridge, NJ Consolidated NDE !n :. 292145201 07/01/88 Exposure Z OH Midwest inspection Services 481616'96 12/18/89 Exposure - t

• 2 means unspecified 2.1.8 Manufacturing and Distribution events. These licensees have no unique reporting requirements for events involving health and safety unless the requirements are incorporated into a The NRC received 33 reports of events that license condition or an Order. None of the events was concemed manufacturing and distribution during significant.

1990. Table 8 provides information about these l l l NUREG 1272, Appendix A A-14 i

Nontoactoro-Events Table 8 Manufacturing and distribution,1990 Isotope Location Licensee License Event Type of Number" Date Event"* Am 241 New Brighton, MN 3M Company 220005706 03/15/90 LKS Am-241 Twinsburg, OH GE Routor Stokes 341623301 08/29/90 LKS Cm-244 Philadelphia, PA Temple University 370069731 11/03/89 LKS Cs 137 Toledo, OH Victoroon. Inc. 342595901 08/21/90 LKS H-3 Picatinny, NJ Dept of Army 290004706 11/01/89 LKS i Blacksburg, VA NL Associated Courlors NL 08/13/90 MS l125 Arlington, IL Amorsham Corporation 12 283602 01/29/90 LAS,TRS l125 Charlotto, NC AS AS 01/10/90 TfGUA 1131 Ciestor, PA NL PA Dept. of Env. Resources NL 11/'6/89 TRS l 31 Pittsburgh, PA Allegheny General Hospital 370131701 11/is/90 tr 192 Columbla, MD NL Nuclotron Corporation NL 05/11/90 TRS Mo 99 Columbus, OH US Alr, Inc. NL 03/13/90 TRS Ni43 NL (Howlett Packard Co ) NL 08/23/90 LKS . oston, MA Bio Toc inc. 202074501 12/05/89 LKS B Ni43 NiG3 St. Paul, MN 3M Company 220005707 01/09/90 LKS Ni43 St. Louis, MO Dept. of Health & Human Serv. 240975502 01/24/90 LKS Ni-63 Princeton, NJ Mobil Oil Company 291409701 12/10/90 LKS Ni43 West Point, PA Merck Sharp & Dohme 370153108 06/29/90 LKS Sr-90 St. Louis. MO Washington Univ. Moci Ctr. 240016711 06/19/90 l.KS Tc 99m Bomidji, MN Northern Med Imaging Inc. 221632801 02/28/90 TRS Tc-9Gm Stamford, CT Syncor international Corp. 062822901 12/19/89 TRS Tc-99m Beverty, MA Mallinckrodt, Inc, 201521501 07/30/90 TTW UA Tc 99rr, East Orange, NJ SyncorInc. 291960801 04/24/90 TRS Tc-99 n Columbus, OH Syncor intomational Corp. 341848401 10/18/90 IRS TcGm Allentown, PA Syncor Inc. 291960801 02/26/90 1RS L dep. Johnson City, TN AS Aerolet Tennesseo inc. AS 03/13/90 TRS U nat. Albuquerc,ue, NM NL Tri State Motor Transport NL 10/13/00 TRSfUA Xo 133 Dallas. T/. E I Dupont Do Nemours & Co. 200032021 01/17/90 FUATF6 Other NJ Mallinckrodt, Inc. 202806401 12/23/90 TRS Z Norwalk, CT Perkin Elmer Corporation 060213508 08/22/90 LKS Z Bedford, MA CIS.US, Inc. 202097303 01/26/89 Z Salisbury, NC GL Consolidated Freightways GL 01/13/90 TRS Z Oklahoma, OK Syncor Inc. 291960801 01/16/90 TRS 2 unspe an,.o

• • AS Agreement State NL non Wennee GL gefMaf dl Dr ensee

- tAs w.t e, ste n wme t.KS leastrN sous te HL M tehme at materw IWJ trdfMf; Ort;IflOD A-15 NUREG-1272, Apperxiix A

AEOD Annual Report,1990 2.1.9 Gauges and Measuring Systems Receipt of an unshielded radiography source at Amersham Corporation, Holders of specific licenses to possess gauges are Deficiencies in brachytherapy program, required to report failures of, or damage to, shielding, on/off mechanisms, or indicators of the gauge, or detection of removable contamination on Three events each of which involved a the gauge. In addition, these licensees must report, pursuant to 10 CFR Part 20, lost or stolen materials, radiographer overexposure, releases of material, and so forth. A significant management breakdown at a Reports of 34 events concerning gauges or medical facility. measuring systems were received during 1990. Table 9 includes information from these reports. None of the events by itself was significant. l 2.2 Abnormal Occurrences in the 1990 Report to Congress on Abnormal Occurrences (AO), events at six NRC licensees were determined to be AOs. The AOs involved the following: l l NUREG-1272, Appendix A A-16

~ = Nonreactors-Events Table 9 Gauges and measuring systems,1990 lsotope' Location Licensee License Event Type of Number" Date Event"* Am-241 ATEC Associates, Inc. 131773201 1i/29/90 TRS Am-241 Danbury, CT Testwell Craig Labs of CT, Inc. 061972001 10/27/89 Am-241 Dryden, MI WW Eng. & Science, Inc. 212584801 11/01/90 Am-241 St. Louis, MI Woodward-Clyde Consultants 241598602 01/24/90 Am-241 St. Ann, MO McClelland Consu'tants 242453901 07/05/90 LAS Am 241 Billings, MT HKM Associates 251749201 06/14/90 Am-241 Helena, MT State of Montana 251149801 04/25/90 Am-241 Kalispell, MT Montana Dept. of Highways 251149401 09/14/89 Am-241 Mt Laurel, NJ Golder Associates, Inc. 292795101 10/15/90 Am-241 Elyria, OH Cleveland Elec. Illuminating 340704303 08/31/90 Am-241 Enon, OH Westinghouse Env. and Geo.- 322118301 11/29/90 LAS Am-241 Oakfield H., OH Solar Testing Labs, Inc. 341811903 12/03/90 TRS Am-241 Westerville, OH Resource International 341853201 06/07/90 LAS Am-241 Fairless H., PA GL USX Corp GL 05/03/90 Am-241 Punxsat'y, PA Doverspike Bro. Coal Co. 372844901 10/02/90 Am-241 San Juan, PR Jaca Sierra, and Rivera 521906401 12/18/89 LAS Am-241 Mauston, WI Mathy Construction Co. 481872201 08/13/90 Cd-109 Allentown, PA GL Air Products and Chemicals GL 07/01/90-Cs-137 Wheaton, MD CTI, Inc. 452363101 05/31/90 LAS Cs-137 Saginaw, M1 General Motors Corp. 210867801 05/12/90 LAS Cs-137 Oak Creek, WI Wisconsin Electric Power 481672901 01/22/90 EXP Cs-137 Huntington, WV AS SWVA (DBA Steel of WV) AS 09/28/90 Cs-137 Sistersville, \\W Union Carbide Chem. and Plas. 470606703 12/06/90 Kr-85 N. Andover, MA AT&T Network Systems 200352701 11/08/90 LKS Kr-85 Portland, ME National Semiconductors 181354103 04/12/90 RLM Kr-85 Westwood, PA Allied Signal, Inc. 371692401 11/21/90 LAS Ni-63 New Orleans, LA Dept. of Army 171675302 09/22/89 LAS - Ni43 Cambridge, MA ERCO/ENSECO 07/15/90 LAS Ni43 St. Paul, MN 3M Company 220005707 01/09/90 LKS Ni-63 Kansas City, MC City of Kansas City 241138801 05/08/90 LAS Sr-90 Springfield, Ml Sweetheart Cup Company Inc. 242446201 11/13/86 LAS Z indianapolis, IN Alt & Witzig Engineering Inc. 131868501 11/01/88 EXP Z W. Lafayette, IN IN Dept of Transportation 1309G8901 07/01/89 EXP Z Paoli, PA National Rolling Mills 371626801 07/10/90

• Z untrecifled l

i " AS Agreement State NL nordlicensee GL generW licerisee '"LAS fast or stolen source Lt $ leaung source ALM release of rnaterial TR$ transportation A 17 NUREG-1272, Appendix A

Nonreactors-Events 3 Findings The number of events that was reported to the NRC in water in an excavation on its plant site, was the subject 1990 was about the same as in previous years. One of an augmented team inspection Exposures to three event, the receipt by Amersham Corporation of a source radiographers in three separate events resulted in doses inside a shipping container thought to be empty, was of 1000 rem to several thousand rem to extremities or the subject of an incident investigation (see NUREG-local body areas. No reported events sonously affected 1405). Another event, the discovery by Sequoyah Fuels the public health and safety. Corporation of a large amount of uranium-contaminated \\ i A-19 NUREG-1272, Appendix A

Appendix B Repod on 1990 Misadministration Events I

Appendix B AEOD/N91-03 Report on 1990 Misadministration Events by the Nonroactor Assessment Staff Office for Analysis ard Evaluation of Operational Data Prepared by Harriet Karaglannis I i l

Table of Contents 1 Introduction B1 i Therapy arxl Diagnostic Misadministrations Reported to NRC During 1990 B-3 2.1 General,. B3 2.2 Therapy Misadministrations B4 2.2 1 Tolotherapy Misadministrations B-3 2.2.2 Brachytherapy Misadministrations 07 2 2.3 Radiopharmaceutical Therapy Misadministrations B8 2.3 Diagnostic Misadministrations B9 2.3.1 Diagnostic Misadministrations of Icxlino B-10 2.3.2 Diagnostic Misadministrations That involvo the Mislabeling of Radiopharmaceutical Dosages by Radiopharmacios B-11 2.4 Abnormal Occurrences B 11 B-13 3 Licensoo Proposed Correctivo Actions 4 FindinOs and Conclusions B 15 Tablos 1 Medical misadministrations reported to NRC during 1990 BC 2 Misadministration reports for 1981-1990 B-4 3 Error rato for misadministrations B4 4 Type and probablo cause of therapy misadministrations reported in 1990 B-5 lil NUREG 1272. Appendix B

1 Introduction The Office for Analysis and Evaluation of Medical misadministrations are reported to the NRC j Operational Data (AEOD) reviews reports of medical pursuant to the requirements in 10 CFR Part 35 All misadministrations of radiopharmaceuticals or therapy misadministrations are required to be radiation from isotopes regulated by the NRC.* reported; the reporting criteria for diagnostic AEOD's review of these reports submitted to the misadministrations require reporting of only those j NRC during 1990 is documented in this appendix. diagnostic misadministrations in which radioactive material not intended for medical use was used; the administered dose was five-fold different from the The revised 10 CFR Part 35, which became effective prescribed dosage; or the patient was likely to on April 1,1987, defines a misadministration to receive an organ dose greater than 2 rem or a mean the administration of - whole-body dose greater than 500 mrem. A radiopharmaceutical or radiation from a sealed source other than the one intended. Approximately 7 million diagnostic procedures and 180,000 therapy procedures are performed nation-A radiopharmaceutical or radiation to the wrong wide each ',aar." It is estimated that about 40

patient, percent of all these procedures are portormed by NRC licensees and those remaining by Agreement A radiopharmaceutical or radiation by a route of State licensees.

administration other than that intended by the prescribing physician, Diagnostic misadministration, as used in NRC A diagnostic dosage of a radiopharmaceutical regulations, refers to the misadministration of differing from the proceribed dosage by more radioisotopos in nuclear medicine studies such as than 50 percent, renal scans and bone scans. Therapy misadminis-tration, as used in NRC regulations, refers to the A therapy dosage of a radiopharmaceutical misadministration of radiation in the treatment of differing from the prescribed dosage by more patients from cobalt-60 teletherapy (external use of than 10 percent, or radiation for patient therapy treatment), brachy-therapy (insertion or implantation of sealed sources A therapy radiation dose from a sealed source containing radioactive materia! for patient therapy such that errors in the source calibration, time treatment), or radiopharmaceutical therapy. The of exposure, and treatment geometry result in significance of any event stems from the potential a calculated total treatment dose differing from effect of the event on the public health and safety. the final prescribed total treatment dose by Generally, the total risk ascribed to an event is a more than 10 percent. function of the frequency of the event and the magnitude of the potential effect of the event. The Atomic Energy Act of 1954. as amended in 1W4. hmits the NRC's regulatiort of radioactive materws to reactor-produced isotopes. Licensees have reported about 100 therapy mis-administrations to the NRC over the 10-year period aus Nucicar neguatory commission. easic ouanty esanince eragram. from 1981 through 1990. The estimated error rate RfCords and Reports of Misadministrations or Events Relating to the per patient is 0.0003 for teletherapy and 0.0002 per i uescat use ov eyprodet uaterw oc cra pet 3s e rte nm~. va

55. N410. January 16.1990. pp.14D1441 B1 NUREG-1272, Appendix B

AEOD Annual Report,1990 procedure for brachytherapy and radio radiophar. hundred rad to several thousand rad. These doses maceutical therapy. may approximate therapy equivalent misadmin-istrations. Generally, the magnitude of the potential or actual effect of a therapy misadministration and a diagnos-Because both therapy misadministrations and tic misadministration differ. Therapy misadminis-diagnostic misadministrations have about the same trations are associated with_ procedures in which estimated error rate, therapy misadministrations and large doses of radiation are administered to patients some iodine-131 misadministrations as a class, to achieve e therapeutic effect, wh!!e diagnostic appear to be individually and collectively more misadministrations are associated with procedures significant than diagnostic misadministrations. requiring small doses of radiation, except for the AEOD, therefore, reviews in detail reports of therapy diagnostic administration of iodine-131. misadministrations and misadministrations that involve the administration of lodine-131. Most reports of diagnostic misadministrations are Licensees have reported approximately 4000 diag-reviewed from a collective or statistical viewpoint. nostic misadministrations to the NRC over the 10-year period from 1981 to 1990. It is estimated that about 3 million procedures are performed annually This appendix is a compilation of data on mis-by NRC licensees, so that the estimated diagnostic administrations reported to the NRC from January patient error rate per procedure is 0.0001. through December 1990 and is divided into the following sections: " Therapy and Diagnostic Misad-ministrations Reported to NRC During 1990," Diagnostic misadministrations that result in the "Ucensee - Proposed Corrective Actions." and erroneous administrati..l of lodine-131 may result in " Findings and Conclusions." - thyroid or organ doses that range from several 4 I NUREG-1272, Appendix B B-2

l 2 Therapy and Diagnostic Misadministrations Reported to NRC During 1990 2.1 General Table 2 lists the number of misadministration reports received during 1990 and the previous nine years This table also provides the number of From January through December 1990, NRC repods according to type of misadministration, the licensees involved in radiation therapy and nuclear number of patients involved, ard the number of medicine reported 24 therapy misadministrations licensees reporting misadministrations. The figue of and 443 diagnostic misadministrations, which is 443 diagnostic reports for 1990 was about 10 equivalent to approximately 16 events per 100 percent higher than the average rate of the 9 licensees. Table 1 summarlzes the statistics for the previous years. The 24 therapy mitadministrations medical misedministrations reported to the NRC for reported during 1990 was about triple the average 1990. Of the approximately 2400 NRC licensees number reported annually in 1981 through 1989. authorized to perform nuclear medicine studies or radiation therapy, 350 reported one misadminis-tration or more for a total of 467 reports involving Table 3 provides estimates of the error rate for the S73 patients. Of the 467 reports on misadministra. various types of therapy procedures and diagnostic tions for 1990,443 (95 percent) involved diagnostic procedures. misadministrations and 24 (5 percent) involved therapy misadministrations. 2.2 Therapy Misadministrations Table 1 Medical misadministrations reported to NRC during 1990 Licensees reported 24 therapy misadministrations during 1990. Of these misadministrations, 16 Misadministration involved teletherapy,8 involved brachytherapy, and 6 involved radiophannaceutical therapy. Table 4 presents data on the type and prcbable cause of Diagnostic Therapy Total the misadministrations. No. of Reports 443 24 467 2.2.1 Teletherapy Misedministrations No. of patients involved 548 25 573 Licensees reported 10 teletherapy misadmini-strations during 1990. Of these, four involved an No. of licensees inadequate review of the patient's chart, two reporting 328 22 350 involved an error in identifying the correct patient, two involved an error in the dose calculation, one mmmon a pit <nis n mun nur i%n me n,ec e aeme, ,mm an..%,towieo enit,em m ma meenwainns = involved an error during the simulation process, and $[sEI$e N[ NtN$n((,[,,., one resulted f *om human error during the treatment. B-3 NUREG-1272. Appendix B

AEOD Annual Report,1990 Of the 10 telethorapy misadministrations prescription by writing *stop prescription" on the reported during 1990, in the first case, a patient therapy prescription page of the patient's chart. was prescribed a cobalt 4iG teletherapy However, the technologist did not see the physi-treatment to the cervical spine to be delivered clan's statement in the patient's chart and delivered over 9 fractions of 278 rads each. After the first a third treatment to the patient. To prevent two fractions were delivered, the prescribing recurrence of this misadministration, the licensee physician decided to stop the treatment to stated that in the future, it will establish a clear reevaluate the patient's cervical spine diagnosis. mechanism for documenting changes in the The prescribing physician modified his original treatment plan. Table 2 Misadministration reports for 1981 1990 Type of Misadmin-istration 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 Total Avg. Therapy 10 4 4 14 4 7 9 12 10 24 98 10 Diagnostic lodine-131 2 3 2 3 3 5 5 7 10 13 53 5 Other 428 414 332 395 377 433 409 386 397 430 4001 400 No. of patients 517 451 437 442 410 495 459 470 486 573 4740 474 No. of licensees reporting 351 355 293 318 293 369 348 344 326 350 3347 335 Table 3 Erros : ate for misadministrations (Based on aggregated 10-year data) f Estimated No. No. of l Type of of Procedures Misadminis-No. of Error l Procedure by NRC Licensees trations Patients Rate Therapy Teletherapy 368,000' 50 122 0.0003 Brachytherapy 184,000 30 30 0.0002 Radiopharmaceutical 115,000 18 18 0.0002 Diagnostic 38,000,000 4066 4715 0.0001 l l 'TNs figure represents the eshmated number of patients that received tetetherapy treatments. NUREG-1272, Appendix B B-4

Nonreactors-Misadministration Events Table 4 Type and probable cause of therapy misadministrations reported in 1990 Teletherapy inadequate review of the patient's chart 4 Error in identifying the correct patient 2 Error in the dose calculation 2 Error during the simuletion process 1 HL. man error during the treatment 1 Brachytherapy Error in identifying the treatment area 1 Error entered into the computer data 2 Equipment malfunction 2 j 1 Lack of training of involved personnel Miscommunication among the licensee stan..... 1 Unintended removal of brachytherapy source by the patient being treated 1 Radiophamiaceutical therapy Error in verifying radiopharmaceutical 3 labeling... 2 Lack of training of involved personnel Error in verifying patient identification 1 and prescribed dosage... i In the third case, a patient was prescribed a in the second case, a patient was prescribed a e cobalt-00 teletherapy treatment to both the right cobalt-60 teletherapy treatment of 200 rads to hip and the thoraco-lumbar spine to be the chest (mediastinum) but received an completed on different days, After the patient unintended dose of 178 rads to the brain. The received the thoraco-lumbar spine treatment, technologist involved in the treatment did not the patient received an additional unintended review the patient's chart to verify the prescrip-dose to the same area of 1200 rads. The staff tion and assumed that the patient should be technologist involved in this treatment failed to recolving brain treatments. To prevent - observe the statement in the patient's chart that recurrence of this type of misadministration, the the treatment to the spine area was completed. licensee stated that a second technologist will Also, the error was not detected during the verify that the treatment set-up is correct by routine chart review. To prevent recurrence of reviewing the treatment chart set-up page and this type of misadministration, the licensee polarold photograph of the field location before stated that in the future, the technologist who administering the treatment. However, the treats a patient will be required to initial the licensee stated this action is contingent upon daily record individually. Also, a stamp with the staff availability. L word " COMPLETE" will be used at the bottom l of the record after completing each treatment. B-5 NUREG 1272, Appendix B

AEOD Annual Repor2,1990 In the fourth case, a patient was prescribed a for the radiation therapy staff included a cobalt 60 teletherapy treatment to the lumbar strengthening of the patient identification policy. spine but received an unintended dose of 250 rads to the thoracic spine. The patient had previously received teletherapy treatments over In the seventh case, a patient was prescribed a the thoracic spine and the tattoo (anatomical cobalt-60 telethorapy treatment to the neck marker) was still visible. The technologist area. A two-part prescription required a dose of involved in this treatment failed to review the 5304 rads to be delivered to the neck area and patient's chart indicating the proper treatment. an additional 1404 rads to be delivered to a Instead, the technologist used the tattoo from tumor located in a specific portion of the neck. the previous treatment. To prevent recurrence After completing the first part of the treatment, of this type of misadministration, the licensee the licensee discovered that only 4619 rads had stated that in the future, all personnel involved been administered to the neck area rather than in such procedures will double < heck patient the prescribed 5304 rads, therefore, the patient set ups with the physician and/or the was underdosed by 13 percent. The second dosimetrist before administering the treatment. part of the treatment was administered as prescribed. The licensee attributed the misadministration to a data entry error in the In the fifth case, a patient was prescribed a dose calculations.To prevent recurrence of this cobalt-60 teletherapy dose to the brain but type of misadministration, the licensee stated received an unintended dose of 45 rads to the that a separate weekly joint review by the lung. The technolo;ist picked up another dosimetrist and the chief therapy technologist patient's chart who was prescribed a lung will be instituted in addition to the routine treatment. The techndogist positioned the weekly chart review conducted by the radiation patient without confirming his identity against therapist. Also, before the first treatment, an the chart and proceeded with the lung treat-independent verification of the calculations will ment. During the treatment, a second technol-be performed by the ph/sicist or dosimetrist as ogist noted the discrepancy between the well as a radiation oncdogist. patient's name and the treatment chart and terminated the treatment. To prevent recurrence of this type of misadministration, the licensee in the eighth case, a patient was prescribed a e stated that all techndogists were counseled on cobalt 40 teletherapy treatment to the whole proper patient identification. brain of 150 rads por treatment. A therapy physicist procedure misinterpreted the prescrip-tion and calculated the treatment time to deliver In the sixth case, a patient who had completed 300 rads per treatment. The error was discov-a cobalt-60 teletherapy treatment and was ered after the sixth treatment during a routine j scheduled for a followup examination received weekly chart review. To prevent recurrence, the an additional estimated unintentional dose to licensee stated that in the future, three inde-the midline of the brain of 296 rads. The pendent individuals will review the treatment followup patient had the same last name as the plan before treatment commences. patient prescribed to receive the brain treatment of 300 rads. The techndogist involved h the treatment did not compare the patient to the In the nin:h case, a patient was prescribed a photograph that was affixed to the medical cobalt-60 teletherapy treatment of a total of chart and began the treatment. To prevent 2000 rads to be given to the left posterior recurrence of this type of misadministration, the cervical lymph nodes. However, during the licensee stated that hservice training provided simulation, the patient was placed in a prone position and the right cervical region was l l-NUREG-1272, Appendix 8 B-6

Nonreactors-Misadministration Events tattoccd, photographed, ard radiographed tration, the licensee stated that the procedures rather than the left. The error was not detected will be re.lsed to require an independent check at the time the simulation film was approved of the treatment plan, the dose printout, ard the ( ard the treatment of 2000 rads to the patient's dose distribution, before initiating the treatment. right side lymph nodes was completed instead of the left The error was detected during a In the second case, a patient was to recetve followup physical examination of the patient To prevent recurrence of this type of misad-treatment for cance: of the lung using an ministration, the licensee stated that the de-iridium-192 brachytherapy sourco controlled by partmental policios and procedures were a computerized device Because incorrect data revised was entered into the computer for the first 1our fractions of the treatment, the source was not plac(d correctly to treat the proper area. As a In the last case, a patient was prescribed a result, the patient received the wrong dose. lo cobalt 00 teletherapy treatment. The treatment prevent recurrence of this type of misad-schadule included four fields for treatment of ministration, the licensoe stated that in the the lymph nodes located in the patient's neck. tuture, the procedures will be revised to require The first two were lateral exposures and these independent checks of the treatment plans and were completed as planned The third field was dose distribution before initiating the treatment. an anterior exposure of the lymph nodes. The prescribed dose to this field was 4500 rads In the third case, a patient was presenbod a However, because of human error, the patient was treated with four additional treatments of transperineal brachytherapy treatment using 180 rads each, resulting in a total dose of 5225 percutaneous implantation of lodine-125 seeds. rads. Radiographs taken after implantation indicated that the majonty of the scods were implanted beyond the body of the prostate This was duo 2.2,2 Brachytherapy MisadministrationS to difficulty in ventying the maximum depth of the prostate and thus positioning the seeds during the implantation. To prevent recurrence Licensees reported a total of eight brachytherapy of this type of misadministration, the licenseo misadministrations during 1990 that were caused by stated that in the future, ultrasound guidance (t) erroneous data entered into the computer, (2) will be used and that the involved urologist and radiation ortcologist will be consulted for treatment of the wrong area. (3) equipment malfunction, (4) lack of training of involved per. verifying the nuximum depth of the prostate. sonnel, (5) miscommunication among the licensee staff, and (6) unintended removal of the source by In the fourth case, a p0tient was prescribed a the patient. transbronchial brachytherapy procedure using an endobronchial catheter. The patient was In the first case, a patient was prescribed a treated using Iridium 192 seeds contained in a brachytherapy tmatment using a remote ribbon with a total actMty of 14.3 millicuries. aftertoading device. The patient was to receive After the treatment, the ribbon and the catheter a total of 3240 rads to each side of the corpus. were to be removed During the removal, a kink However, because erroneous information was was noted in the catheter. The licensee entered into the control computer for the presumed that th6

• ink developed before second fraction of the treatment, the patient loading the seeds, and, as a result, the seeds received 4120 rac's to the treatment area To had not been placed at the interxkd position for the treatment.

prevent recurrence of this type of misadminis-B-7 NUREG 1272, Appendix B

AEOD Annual Report,1990 had not been placed at the intended position for the treatment. In the seventh case, the radiation oncologist prescribed a dose of 3000 rads using a ceslum-137 brachytherapy device. Before initiating In the fifth case, a patient was prescribed a treatment, the dosimetrist involved in the cesium-137 brachytherapy treatment using a procedure revised the original treatment plan remote afterloading brachytherapy device. that was then approved by the radiation oncolo-During the procedure, a malfunction of the gist. The physicist involved in loading the device disconnected the tube used to transfer cesium-137 sources into an applicator used the the sources from the shielded storage unit to originalinstead of the revised treatment plan. As the patient. The disconnection resulted in one a result, the patient received 1464 rads instead of the ceslum-137 sources being located for an of the prescribed 3000 rads to the treatment undetermined time near the upper part of the area. patient's leg, rather than in the patient. The licensee estimated that the patient received an unintended dose from 23 rem to 23,700 rem. To In the eighth case, a brachytherapy procedure prevent recurrence of this type of misadmin-was used for the treatment of cancer of the istration, the licensee stated that the device was uterine cervix. Five cesium-137 sources were removed from service for evaluation by the loaded into an applicator in the patient's room, manufacturer and that the faulty connectors During a routine check, the nursing staff found have been replaced by a design proven to that the patient had pullod out the applicator operate property. causing unintended exposure to her legs. The licensee estimated that as a rc. jlt of this type of incident, the patient received 17 percent less In the sixth case, a patient was prescribed an than the total prescribed dose to the treatment endobronchial brachytherapy procedure of 2500 area and the patient's legs received rads using Iridium-192 ribbon-encased deeds. approximately 623 rads. To prevent recurrence The ribbon was inserted in an endobronchial of this incident, the licensee stated that in the tube placed in the patient's lung. The treatment future, patients will be restrained as needed was inadvertently interrupted when the catheter according to the judgment of the nursing staff, and the ribbon containing the seeds came loose from the treated area. The nursing staff attending the ratient taped the dislodged 2.2.3 Radiopharmaceutical Therapy catheter containbg the ribbon to the left side of MISadministratioris the patient's face immediately in front of the ear. Three hours later, the charge nurse noted the dislodged catheter and, following the Licensees reported a total of six radiopharmaceuti-Radiation Safety Officer's airections, removed cat therapy misadministrations during 1990. All six the catheter and the rit6on and placed it in a misadministrations involved the administration of the lead pig in the patient's room. The licensee wrong dosage to patients. They were caused by estimated that the patient's face received an lack of (1) verifying radiopharmaceutical labeling unintended dose of approximately 1000 rads-and volume, (2) training of involved personnel, and To prevent recurrence of this type of misad' (3) verifying patient identification and prescribed ~ ministration, the licensee stated that they will dosage. adopt corrective measures that will include safety measures to secure the implant ribbon in l-the catheter and that they will revise the training In the first case, a patient was administered 315 l program for the nursing staff and the attending millicuries of lodine-131 Instead of the I physician. NUREG-1272, Appendix B B-8 l

Nontoactnrs - Misauministration Events In the fifth caso, two patients were administerod proscribed dosage of 175 millicuries of lodino. 131. The administering technologist pick (d up wrong dosagos for the troatment of ossoous the two vials containing iodino 131 from the metastatic disease using strontium 89 chlorkle fumo nood located in the nuclear pharmacy. (FDA Phaso ill clinical trials). One of the One vial contained 175 millicuries of iodino 131 patients was to be administond 3.54 millicuries and the second vial containod 140 millicurios of of strontium 89 but instead was administond kdino-131. The technologist did not review the 4 51 millicuries The other patient was labols on the containers and assuming they proscribed 2.87 millicurios of strontium 89 but containod the prescritxx1 dosage, administered instead was administered 4 02 millicuries. them to the patient. In the sixth caso, a patient was prescribed 270 In the second caso, a patient was prescribed millicuries of dysprosium 165 for ablation of the 100 millicurlos of iodino-135 for thyroid ablation. synovium of the knoo However, the patient was However, the patient was administorcd 110.1 administered only 180 millicuries The licensoo milicuries of lodino-131. Although the licensoo stated that this misadministration was due to personnel involved in this proceduto assaytd the incorrectly recorded volume of the tne ordered dosago and the doso calibrator administered radiopharmacoutical To prevent gave a reading of 110.1 millicuries of iodino-recurrence of this type of misadministration, the 131, no adjustments woro made for the licensoo also stalud that in the futuro, strict administered dosage. attention will be paid to recording ard checking volumes and calculating specific activitios. In the third caso, a patient was prescribed 50 millicuries of iodine 131 for thyroid ablation. The 2,3 Diagnostic Misadministrations technologist involved in this procedure measured the dosage in the doso calibrator to be 56.37 millicurios. The measured dosage, Of the 443 reports of diagnostic misadministrations which was more than 110 percent of that pro-received in 1990, 71 percent involved the scribed, was administered to the patient. The administration of the wrong radiopharmaceutical to licenseo stated that in the fututa, the measure-a patient and 23 porcent involved the administration mont and the administration of lodino dosages of a radiopharmaceutical to the wrong patient (those will be supervised by a physicist. two types of misadministrations accounted for 94 percent of the reported misadministrations). Of the remaining diagnostic misadmhistrations,20lnvolved In the fourth caso, two patients woro scheduled a diagnostic dose of a radiopharmaceutical that to recolvo Lodino 131 for thyroid procedures differed from the proscribed doso by more than 50 One of the patients was prescribed 14 porcent and 8 involved the wrong route of millicurios of kdino-131 and the other 20 milti-administration (that is, a routo of administration curies of iodino-131. The technologist involved other than the one intended by the prescribing in these procedures mistakenly gave the 20-physician). The number of diagnostic reports for millicurie dosage to the patient schedukd to 1990 was about 10 percent higher than the average receive 14 millicuries of iodino-131. Tho licensoo rate for each of tho 9 previous years. The annual stated that a now system was developed for number of diagnostic reports from 1981 through cross-checking therapy dosages with the 199) ranged from 334 in 1983 to 443 in 1990, an proscription and patient identification average of 400 por year. The types and causes of the diagnostic misadministrations were about the same as those reported in previous years. In offect, all of the diagnostic misadministrations involving the B9 NUREG 1272, Apperdix B

AEOD Annual Report,1990 Student technologist involved. wrong radiopharmaceutical or the wrong patient stem from human error. The primary errors asso-ciated with the administration of a radiopharma-ceutical to a patient were errors during the prepa-Relatively simple quality assurance procedures ration or administration of radiopharmaceutical (checking the patient's identification against the dosages, such as - study and the patient's medical history, asking the patient to state his or her name) might reduce the Selection of the wrong vial when drawing a frequency o' these events.

dosage, Selection of the wrong syringe from the dosage 2.3.1 Diagnostic Misadministrations of cart-lodine Misinterpretation of the physician's order, Of the 443 diagnostic misadministrations reported to Reconstitution of the wrong reagent kit' the NRC in 1990,13 involved the administration of iodine-131 in amounts that resulted in the delivery Misunderstanding the radiopharmaceutical or of thyroid or organ doses that ranged from 10 the dosage order

• mrads to 3400 rads. Causes of the lodine 131 misadministrations included (1) listing the wrong dosage in the department's procedure manual, (2)

The primary errors ascociated with the administra-misunderstanding the referring physician's request, tion of a radiopharmaceutical to the wrong patient (3) ordering the incorrect dosage from a were - radiopharmacy. (4) not checking patient's chart, (5) selecting the wrong vial when drawing dosage, and Patient's identity was not correlated with the (6) misreading the dose calibrator. correct study, Study was requested for wrong patient, Two of these misadministrations resulted in thyroid doses of more than 1000 rads. In the first case, a Wrong patient was delivered to the nuclear patient was prescribed a substernal thyroid scan. moolcine department, The technologist responsible for the administration of the dosage referred to the department's Patient answered to the wrong name. procedure manual. The manual indicated that the proper dose for a substernal thyroid gland study was 3 to 5 millicuries of lodine-131 or 100 to 200 Licensees stated that contributing factors for these microcuries of iodine-123. As a result, the patient primary errors were - was administered 4.3 millicuries of iodine-131. However, the dosage listed in the procedure manual Heavy workload, was wrong. The standard dose for a substernal thyroid scan should have been 50 to 100 Patient's identification bracelet not checked, microcuries of iodine-131. On the basis of certain assumptions, a consultant estimated that the patient Patient's chart no: checked received a dose of 3400 rads to the thyroid gland. Patiant's requisition not checked, in the second case, a patient was prescribed a New employee involved. thyroid scan requiring a dosage of 300 microcuries l NUREG-1272, Appendix B B-10

Nonreactors-Misadministration Events Two medical brachythorapy misadministrations of lodine 123 that should have delivered about 4 rads to the thyroid gland. However, the licensee that involved equipment malfunction, misunderstood the referring physician's request, interpreting the request as an iodine whole-txxjy Two modical brachytherapy misadministrations thyroid scan. As a result, the patient was adminis-tered 1.4 millicuries of lodine-131 that delivered that involved incorrect information entered into about 1800 rads to the thyroid. the computer, A medical t'rachytherapy misadministration that 2.3.2 Diagnostic Misadministrations That involve the Mislabeling of involved lack of training of licenseo personnoi p rticipating in the treatment, RadiopharmaceuticalDosages by Radiopharmacles Three medical cobaltf;0 toletherapy misadmin-About 6 percent of the total 443 diagnostic misadministrations resulted from radiopharm-aceuticals ordered from radiopharmacies. The Two medical cobalt 60 teletherapy misadminis-causal factors associated with these misad-trations that involved inadequato review of the ministrations included (1) selecting the wrong vial simulation treatment plan, when drawing a dosage, (2) mislabeling a syringe conta:ning a radiopharmaceutical, (3) placing a reconstituted vial in a wrong vial shield, and (4) A medical cobalt-60 teletherapy misadministry reconstituting the wrong reagent kit. However, tion that involved difficulty in identifying th because radiopharmacios can supply many treatment area of the patient's anatomy, hospitals, a single mislabeling event could result in the administration of the wrong radiopharmaceutical to many patients. Licensees reported 37 patients A medical radiopharmaceutical therapy misad-recotved misadministrations as a result of an error ministration for which dosago labols were not that occurred at a radiopharmacy. As previously reviewed before administration, indicated in this appendix, the calculated error rato for diagnostic misadministrations from reported data is very low 0.01 percent; however, radiopharmacy A medical diagnostic misadministration that practice appears to be an area in which efforts involved miscommunication about the pro-expended to reduce human errors could be scribed dosage of iodine-131, productive. A medical diagnostic misadministration that 2.4 Abnormal Occurrences involved the wrong dosage of lodine 131 listed in the department's procedure manual, in the Report to Congress on Abnomial Occur-rences (AOs) for 1990,20 medical misadministration A medical diagnostic misadmlaistration that events were determined to be AOs. Of these,18 involved an order from a radiopharmacy of the occurred in the NRC-regulated states and 2 in incorrect dosage of iodine-131, Agreement Shtes. The AOs for NRC licensees included - i B-11 NUREG-1272, Appendix B l

i AEOD Annual Report,1990 A medical diagnostic misadministration that The AOs for Agreement State licensees included - involved lack of training of the technologist A medical brachytherapy misadministration that administering a dosage of technetlum-99m, involved equipment malfunction, A medical diagnostic misadministration for A medical diagnostic misadministration for which a dosage of technetium-99m was not assayed before administration. which a dosage of lodine-131 was not assayed before administration. NUREG-1272, Appendix B B-12

l 3 Uconseo Proposed Corrective Actions Implementing new procedures for patient To prevent recurrence of misadministrations that occurred in 1990, licensees took the following kjentification. corrective actions most frequently; As the corrective actions and their effectiveness are Reinstructing personnel, licensee-specific, a meaningful determination of whether corrective actions were effective would have to focus on the trend in misadministration Reprimanding the technologist or other person-rates for each licensee that reported several

nel, misadministrations. Because the reported misad-ministration rate estimated for a sample of licensees was 0.1 percent, a very small number, a detailed Implementing new radiopharmaceuticallabeling evaluation of these rates and their associated and handling procedures, corrective actions has not been rnado.

Implementing new procedures that require the technologist to check the patient's request, and B 13 NUREG-1272, Appendix B

4 Findings and Conclusions Licensees reported 24 therapy misadministrations number of diagnostic reports for 19JO was about 10 during 1990, a number that is about three times porcent higher than the averago rate for each of the higher than the average number reported for 9 previous years The causos reported bylicensoes previous years These tolotherapy, brachytherapy, for 1940 are, generally, simpio errors associated and radiopharmacoutical t hera py misad minist rat kins with the preparation ard adrninistration of radioph. might have boon provented by quality assurance armaceuticals, such as (1) processing nuclear proudures that domarded patient cPart review, rnodical requisitions, (?) reading dosage and del verification of patient doso calculations, verification labels, and (3) klontifying pationts. In addition, for of the type of proscribed treatment, kjentification of misadministrations involving kxhno 131, the primary the correct treatment area, and patient kjentification causos given wero (1) misury'orstanding a physician's order, (2) picking up the wrong radio-pharmaceutical, (3) ordering the incorrect dosago Most diagnostic misadministrations for 1930 f r om a radiopharmacy, (4) not checking the involved either the administration of the wron0 patient's chart, (5) misreading the dose calibrator, radiopharmaceutical or the administsation of a and (6) hsting the wrong dosage in the department's radiopharmaceutical to the wrong patient. The procedure manual. B 15 NUREG-1272, Appendix B

Appendix C Summary of 1990 Abnormal Occurrences (Nonreactors) et i

l Abnormal Occurrences (AOs) for CY 1990 (Nonreactors) NUREG-0090, Volume 13, No.1, On February 2, 1990, Ball Memorial Hospital Report No. 90-2 report (d that a thorapy misadministration was Medical Therapy Misadministration discovered earlier that day in the treatment of a patient foi lung cancer. The intended procoduro called for 1500 rom to the right tung area. A ribbon On January 17,1990, Monongahela Valloy Hospital holding sovon soods (small scaled radiation notified the NRC that a coslum-137 brachytherapy sourcos) contalning a total of 14 3 milliculios of source had becomo dislodged from its applicator iridium 192 was to be inserted into the patient's lurg while a patient wa Ming treated for uterino cancer after a catheter had boon inserted. Betwoon the timo as the result of a malfunction of a remoto the catheter was inserted and the time the iridium-afterioading brachythorapy device. The rnalfuncilon 192 soods woro placed in the cathotor, a kink resulted in the disconnection of the tubo used to developed in the cathotor. Because of the kink, the transfer the coslum 137 sources from the shielded soods woro not inserted into the intended location stora00 unit to the patient. The disconnect resulted in the lung, but rather romalnod in the pharynx aroa in one soutco being located for an undeterminod about 25 centimeters (about 10 inchos) from the time near the pationt's upper log rather than in the intended treatment area. The proceduin was patient. repeated on the following day, and the intoided luag aroa was successfully exposed. The licensoo initially estimated a dose to the patient's leg from 23 rom to 23,700 rom. Three The licensoo roportod that no complications resulted physical examinations of the patient have Indicated from the misadministration. A medical consultant no visible signs of radiation damage to dato, Indi-retained by the NRC concluded that the misadminis-cating that the actual exposure was at the lower tration would not be of clinical significance because end of the range. Additional future examinations of of the localized nature of the radiation doso and the the patient will be performed. area affected Based upon visual examination of the failed NUREG 0090, Volume 13, ho.1, equipment by NRC inspectors, the failure appeared Report No. 90-4 to be caused by inadequato equipment design or Medical Therapy Misadministrations the use of faulty materialin the retalning ring of the connector that attached to the applicator. The device was removed from service for ovaluation by On February 7,1990, and March 15,1990, two the manufacturor. The faulty connectors have boon therapy misadministrations occurred at the replaced. University of Wisconsin as a result of incorrect data being entered into a computer. The second event resulted in the wrong part of a patient's body NUREG-0000, Volume 13, No.1, rocciving a therapy doso. Report No. 90-3 Medical Therapy Misadministration The treatmonts woro performed using an after-loading devico that inserts a high intensity iridium-C1 NUREG-1272, Appendix C

- - ~ __ _. AEOD Annual Report.1990 192 source (nominally 10.;urios) 11e e tube The technologist, the supervising technolog!st, and previously placed in the treatr%. s a. The the chlof technologist became aware of the stop placoment and movement of the radia.. source treatment order lator that day. are controlled by a computer, allowing procise placomont and timing TM attending physician stated that he did not teneve the additional treatmont of 278 rem would in the first instance, a 42 yoar-old riatient recekod be clinically harmful to the patient. He based his a dose to one area that was 27 percent higher than ovaluation on the fact that, among other things the proscribed. The error was detectsd ord a revised dose rate was far below a dose rate that would be prescription was administered.

• dolotorious' to spinal cord tissue, and because he still has the option of resuming treatments. The patient's symptoms have improved s!nce the The second misadministration involved a 06 year-old troatments have been haltod. The physician plans to patient being treated for a bronchial tumor.

withhold further treatments if improvements con-Inconoct information was ontored into the computor tinue. for the firt. of four 400-rom treatments, resulting in the incorrect placement of the Iridium 192 source. The troatod area was about 9 contimotors (about 3 5 NUREG 0090, Volume i3, No.1, inches) from the Intendod treatment point. When the Report No. 90-6 error was discovered, th3 licensee repeated the Medical Therapy Misadministration procedure to provide tho intended dose to the intended treatment area.1he romalnder of the treat-o' nts woro performod without incident. On February 16,1990. Washington Hospital Contor notified the NRC that a therapy misadministration occurred when the wrong patient was administered NUREG-0090, Volume 13, No.1, 45 rem to the lung from a tolotherapy machina. The Report No. 90 5 radiation therapy technologist callod patient A's Medica: Therapy Misadministration name, but the wrong patient (patient B) responded. The technologist did not confirm the pa', lent's identity with pationt B's wrist band or the name on On February 15,1990. Clovoland Clinic Foundation the hospital chart. The technolo0lst togethor with a notiflod the NRC of a potemial misadministration, second technologist procooded with the treatment. Involving cobalt 40 telethorapy that occurred on The second technologist noticed that the name on February 8,1990. The patient recekod a dose 50 patient B's hospital chart did not match the name percent greater than the physician's preschbod on the department treatmont chart and terminated dose. A physician proscribed nine treatments of 278 the treatment. The patient was then identiflod as rom each for a 62 year-o'd patient. Following the patient B who was at the hospital for radiation first two treatments, the physician decided to stop therapy to the brain. the treatments to reevaluate the cervical spine area diagnosis. The physician wroto a 'stop proscription

• on the first page of the patient's treatment chart.

The licensee has advised the NRC that no adverse l The technologist did not see the stop treatment effects are anticipated as a result of the misadminis-order since he tumed to the second page whero no tration. change was !!sted, The patient subsequently l received 278 rem to the cervical spino. I l NUREG 1072, Appendix C C-2

I Nontoactors-Abnormal Occurrencos NUREG-0090, Volume 13, No,1, other Irdtvkiuals who may have boon in closo Report No. 90-7 proximity to the sourco for extended ponods, Receipt of an Unshielded Radioactive Source cytogenetic studios performod on tho flvo at Amersham Corporation in Durlington, individuals that had the highest potential for Massachusetts exposure st,ggest that the sourco may have romalnod shloided so that no actual exposures occurnd until the shipment was transferrod from On March 8,1990, Amorsham Corporation informed storago in Boston to Amorsham's faclitty in NRC that a shipmont of 14 Model 500-SU sourco Buriington, Massachusetts. changers (reportodly empty) recolved from its cu%nor, NDI Corporation, Seoul, Korea, containod NUREG-0090, Volume 13, No.1, an unshloided radioactivo source The woodon crato Report No. 90-8 containing the source changers was not labellod as Medical Therapy Misadministration containing radioactive matorLal. Shipping documents indicated that the source changers were empty. However, toutino surveys of the crato at On March 16, 1990, Riverside Regional Modical Amersham's Burlington, Massachusetts facility Contor notified NRC that a therapy misadministra-revealed a radiation level of about 100 millirem por tion had occurred when the wrong patient was hnur noar the back of the truck thtt delivered the administered 296 rads (from a tolotherapy unit) to package to Amersham and about 10 rem per hout the midlino of the brain The radiation therapy noar the package. Subsequent surveys revealed technologist had Dono to the waitirig room and levels of about 150 rom por hour, a sign lficant called for the patient by sumamo only. radiation level, at contact with the source changer (approximately 4 to 6 inches from the source) The licensoo retrieved the radiography sourco from an However, the techrWngist did not properly identify interior, unshiolded part of a source changer The the patient before treatment by comparing the licensoo stated that the sourco had boon cut from patient to the photograph affixod to the modical its pigtall connector. chart. The patients in question had the same last name and first initial, were of the same race and gender, were approximately the same ago, had inquiries mm;o by NRC and Amersham inoicsad approximately the same troatment rogion, the same that the package left Pusan, Korea by ship on treatment technologut,9nd approximately the same Januo y W,1990; tise ship arrived in Los Angeles, appointment time. Callfemia, on February 11,1990, and the crate was offloided and trucked to Amersham. The licensoo has advisoa the NRC that no adverse offects are anticipated as a result of the misadminis-An NRC incident Investigation Team (IIT) was tration. O'Danized on March 9,1990, and completed its investigation in April 1990. The team report was lasued in May 1990 as NUREG-1405, ' Inadvertent NUREG 0090, Volume 13, No.1, Bhlpment of a Radiographic Source fiom Korea to Report No,90-9 / morsham Corporation, ?n Burlington, Massachu. Medical Therapy Misadministration setts.* On March 16, 1990, John F. Kennedy Memorial Although the maximum estimated potential whole-Hospital notified NRC that a patient receMng an body radiation exposures range from 27 to 35 rom ondobronchial Iridium 192 treatment reconed an for tveo long distance drivers, and 0.5 to 5.6 rem for unintended therapy doso to the f ace. The misadmin-l C-3 NUREG 1272, Appendix C

. ~ - - AEOD Annual R port,1990 lstration was estimated to have occurrod from as that day, the pationt was soon by an ophthalmo-early as 10:30 p m. March 15, to midnight whon it logist who diagnosed the condition as koratocon. was first observed, and continued to approxirnatoly junctMtist the doctor said that this condition could 4:45 a.m. on March 16 when the Iridium was be viral related but did not rule out the possibility of removed to a load shloided container. radiation-induced conjunctMtis. The patient was dischargod from the hospital the following day. The misadmin!stration occurrod when a ribbon containing 25 seeds, inserted into a previously An NRC modical consultant reviewod the event and placed endotrachoal catheter, became displacod. concluded that the patient should not have any The cathoter remalnod h place. However, the long term advorse offects except for the remoto ribbon containing the Irkilum seeds became possibility of change in the lens of the eye. completely dislodged from the cathoter and came to rest beside the patient's face. The ribbon remalnod unsocured until 2:00 a.m. when the duty NUREG-0090, Volume 13, No.1 nurse tapod the unsecured end containing the Report No. 9010 Irldlum soods to the left side of the patient's face, Medical Therapy Misadministration where it remained for approximately 3 hours. On March 19, 1990, St. Mary's Modical Contor At about 4:15 a.m., the charge nurse, noticing the reported to NRC that a 40 year old patient recolved dislodgod source, called the Radiation Safety Officer a therapy radiation dose of 250 rom to the thoracic who directed removal of the ribbon from the patient portion of the spine rather than to the lumbar tsIng a remote hand!Ing toot The source was portion which is a lower portion of the spino _ placed in a shloided container, The patient had previously recofvod a 1otal radiation The liconsee maue preliminary dose estimatos of dose of about 4500 rem to the thoracic portion of 1032 rem to the left side of the patient's face,282 the spine during April 1986 and December 1987, in rom to the eyes, and 357 rem to the scalp since the March 1990, a proscription for treatment to the patient at one point folded the ribbon in her hair, lumbar portion of the spine was preparod. On The duty nurse who handled the ribbon recolved an March 19,1990, the patient received the first est% toc 17.6 rem to the fingers. treatment of the series, but the radiation technolo-gist mistakenly admlnistored a 250 rom dose to the thoracic splne rather than the lumbar portion of the At7:3r a.m. on March 16, the radiatio,1 oncologist spino. The technologist then reviewed the patient's rothreadod the iridium ribbon through the cathoter chart and immediately realized the error, and the pat!ent's endobronchial treatment was continued, ending at 9.30 p.m. the same day. The patient was discharged from the hospital on The unintended treatment of the thoracic area March 20,1990. The licensee advised the NRC that brought the total radiation dose to that area to no adverse offects wore anticipated as a rosult of approximately 4800 rom. The licensee stated that the misadministration. there is a low probability of radiation damage to the spinal cord from a total radiation dose of this magnitude. The patient will be monitored for However, at 1:00 a.m. on March 22,1990, the possible future conditions, but no medical treatment patient was roadmitted to the hospital complaining is required for the additional radiation dose. of burning eyeballs and sensitivity to light. The patient's eyes were medicated and banda00d. Later NUREG-1272, Appendix C C-4

Nontoactors-- Abnormal Occurrences The technologist failed to follow n3rmal treatment NUREG 0090, Volume 13, No. 2, procedutos that iequire technologists to review the Report No. 90-12 patient's chart, examine the X ray film showing the Radiation Overexposure of a Radiographer treatment area, and obtain verification of the treatment setup by a second tochnologist, before initiating treatment. On the ovoning of April 6,1990, Barnott Industrial X Ray notified the NRC that an incident had occurrod earlier that ovening while a radiographor The NRC retained a modical consultant to evaluato and his assistant woro working at a temporary job the circumstancos of the misadministration and site in Ardmoro, Oklahoma The radlographic possible consoquences The consultant agrood with operation used a radiography device containing an the licensoo's evaluation. approximately 00-curio Irkilum 192 scaled source. The licensoo reported that the soutco became disconnected from the drivo cable and remalnod in NUREG-0090, Volume 13, No. 2, the sourco guido tube. Falling to conduct a Report No. 90-11 radiation survey of the exposure device and hence Deficiencies in Drachytherapy Program unaware that the sourco romalnod in the tube, the assistant, after disconnecting the sourco guido tube from the radiography device, wrapped the sourco On March 28, 1990, NRC recolved allegations guide tube around his neck while he moved portaining to brachytherapy treatments at the St equipment at the work site. The licensoo initially Mary Modical Conter facilities in Gary and Hobart, estimated that the assistant rocolved an exposure of Indiana. The NRC also conducted a special 4000 rom to the exposed area of his neck, inspection at Portor Momortal Hospital in Valparalso, Indiana. Although the original allegations did not include Porter Memorial Hospital, the NRC Both the assistant and radiographer were referred to inspection was made because brachytherapy a radiation oncologist for examination and blood procedures at Porter Memorial Hospital were samplos wor 1 obtainod. The cytogenetic studios performed by the same physician as those at the St. revoakd equivalent whole-body dosos of 17 rom for Mary facilities. the radiographer and 24 rom for the assistant. The assistant developed an area of crythema on the left side of his neck, which later showed signs of more The alleger contended that the authorized user did significant damage to skin tissue in an eroa approxi-not evaluate patients' treatment plans before mately 10 contimotors in diamotor. The oncologist treatment and that the patients therefore did not determined that the observed 9tiect corresponded recolve the prescribed dose of radiation during the to a local skin dose of 5000 to 7000 rom. As of June proceduro. The NRC concluded that the two St. 1990, the skin tissuo in this area had regoriorated Mary facilities were not exercising adoquate and the physician did not predict any long-term management control to assure that NRC require-offects as a result of this exposure. The assistant monts were mot. remains under the physician's care. There were no modical ottocts observod for the radiographer. The NRC determinod that adequate records had not boon maintained at the Porter Memorial Hospital to evaluate whether or not the brachytherapy pro-codures had boon administerd as proscribed and plannod. C-5 NUREG-1272 Appendix C

AEOD Annual Report,1990 NUREG 0090, Volume 13, No. 2, HUREG-0090, Volume 13, No. 2, l Report No,90-13 Report No. 9014 Medical Diagnostic Misadministration Administration of lodine-131 to a Lactating Female With Uptake Dy Her Infant On June 8,1990, Mercy Memorial Medical Contor reported a diagnostic misadministration to the NRC. On June 19,1990, a nursing mother at the Triptor A 79-yoar-old female patient was schodulod to Army Medical Center was glvon a 4.89-millicurie undergo a diagnostic evaluation to determine dose of lodine-131 that resuttod in an unintentional whether she was suffering from an enlargod thyroid radiation dose to her infant's thyroid gland gland (substomat thyroid). No prescribed dose was estimated at 30.000 rads and a dose to the infant's indicated. whole body of 17 rads. The error was detected on June 21,1990, when the patient retumod to the medical contor for a whole body scan. The scan The technologist, in attempting to order the propor indicated an unusually high broast-uptake of amount of radioactive material, noted that her lodino-131. In the opinion of the patient's physician standard dose chart (creaf9d by authorized users) and an NRC medical consultant, the Infant's thyroid did hot list dosage for a substernal thyroid gland function will be completely lost. The infant will study. The technologist then referred to the require artificial thyroid hormone medication for life department's procodures manual, which Indicated to ensure normal growth and development. that the proper doso for a substernal thyroid gland study was 3 to 5 millicuries of lodine-131 or 100 to 200 microcurios of lodine-123 The tochnologist thon The physician and nuclear modicine technologist asked an authorized user which isotopo to use. The failed to confirm that the patient was not authorized user told the technologist to order breastfooding. The pationt arrived at the medical enough iodine-131 to visualize the thyroid gland. On contor from a remote South Pacific island. June 5,1990, the patient was given 4.3 millicurios of Communication between the island physician and lodine 131, which conformed to the procedures the Army physicians was poor and the Triptor manual. The dosage listed in the procedure, Sospital physicians were not aware that the mother however, was wrong. The standard doso for a had given birth on June 1,1990. substomal thyroid scan should have been 50 to 100 microcuries of iodine 131, or approximately one-fiftieth of the amount noted in the manual. The NUREG-0090, Volume 13, No. 2, mistake was identified by the Chief of the Nuclear Report No. 90-15 Medicine Department on June 6 and reported as a Medical Therapy Misadministration misadministration to the NRC on June 8,1990 On June 22,1990, St. Luke's Hospital reported that The licensoe estimated that the misadministration a 57-year-old woman being treated for lung cancer resulted in a mean dose to the thyroid gland of was erroneously given a 178-rem radiation dose to 5752 rads. The NRC's medical consultant investi-the loft side of the head on June 22,1990, instead gated the case. On the basis of certain of a 200. rom radiation dose to the chest area. A assumptions, the consultant estimated the dose to technologist set the patient up for brain irradiation be 3400 rads to the thyroid g!and which, according without looking at the treatrnent documents. i-to the consultant, would yield a 10 percent chance Because the misadministration involved a single l of hypothyroidism over 5 years. The licensee is treatment and because of the dosage involved, no i monitoring the patient's condition. adverse medical effects are expected by the l !!censee. NUREG 1272, Appendix C C4 i i i

Nonroactors-Abnonnal Occurronces NUREG-0090, Volume 13, No. 3, On June 1,1990, NRC was notified by Overlook Repor1 No. 90-16 Hospital that a diagnostic misadministration Medical Therapy Misadministration invohring lodino 131 had occurrod at the hospital. On September 19, 1990, Muskogee Regional An outpatient was schodulod for a nuclear modicino Medical Centor notiflod the NRC that a therapy study by the referring physician's offico by misadministration had occurred involving a tolophone. The nuclear modicine department treatment administered from February 20 to March unden,tood the doctor's offico to request an 12,19% The radiation oncologist had identified the appointment for an iodine 13t scan, The patient treatment error on September 6,1990, but had not brought the written proscription to the outpatient immodlatoly recognized it to be reportable. The department ard then procoodod to the nuclear troatment error involved administration of 2160 rads modicino department for the schedulod study. The to the right postorior neck of a patient rather than written prescription was not rocoived by the nuclear the left posterior neck as prescribod. mndicine department Until after tho study was completed. When the nuclear modicine department recolved the writton proscription, the roferring physi-The oncologist had initially participated in the clan's writton prescription requestod a thyroid scan, treatment simulation and approved simu'ation not an lodine-131 scan. The patient had a normally radiographs before to treatmont; however, the functioning thyroid. physician failed to notice that the wrong side of the patient's neck had boon the subject of the simula-tion. This error was attributed to the fact that the The intended dose to the patient's thyrokJ was patient treatment was simulated in the prone approximately 4 rads from 300 microcuries of position rather than in the routino supino position. lodino 123. The administered dose to the thyroid was approximately 1820 rads from 1.4 millicuries of iodine 131. The licensoo does not expect any The oncologist had palpahd an enlarged cervical significant consequences to the patient. lymph node on the patient's left side during the September 6,1990, physical examination which prompted his subsequent review of the treatment NUREG-0090, Volume 13, No. 3, chart and ideatification of the error. All treatment Report No. 90-18 records indicated that the right side of the patient's Significant Dreakdown in Management neck was treated, although the prescription clearly and Procedural Controls at a Medical Facility indicated that treatment was to be glvon to the left side. On August 14,1990, North Detroit Gonoral Hospital reported to NRC that films from diagnostic nuclear The licensee's radiation oncologist has advised the medicine studies were apparently fraudulent. The NRC that no adverse effects were observed during films involved 30 studios performed on 27 patients routine followup examinations and that no signi-during the time period July 19 to 27,1990, During ficant offects are antic! pated as a result of the this period, a replacement technologist supplied by misadministration, a temporary services contractor was being used by the lic6nseo. The licenseo subsequently determined that the films for 29 of the 30 proceduros were NUREG-0090, Volume 13, No. 3, fraudulent or indotorminato and were, therefore, Report No,90-17 unreliable for patient diagnosis The films in ques-Medical Diagnostic Misadministration tion show evidence of tampering The fraudulent films were discovered by the staff technologist by C7 NUREG-1272, Apperdix C

AEOD Annual Report,1990 comparison with later films attor the contract toch-with incorrect amounts of l 131. The dose to the nologist had left. The licensoo then reviewod the thyroid, based upon the resu!!s of an uptake scan, films from procodutos performod by the contract was calculated at 3 9 porcent uptake, resulting in an t echnologist. The licensee's investigation d ot ormined estimated actual dose to the thyrold of 29 rads. The "conclusNely that the individual had doctorod and licensoo does not expect any adverse conse-provided fraudulent nuclear modicino studios for quences to the patient. intsrpretation. The technologist had submitted nuclear modicine studios on patients who had previously been imaged within the Departmont NUREG-0090, Volume 13, No. 3, during the past 2 years ard altered the namos on Report No. 90-20 those Images and placed the names of the patients Medical Diagnostic Misadministration he was to have performed studios on in their placo? On September 24,1990, a consuttant to West Shore The licensoo was unable to determine, in mcst Hospital informed NRC that an 84 year-old female casos, whether the diagnostic proctduros had cancer patient received a 175 millicurie doso of a actually boon performod and whether the patients 19chnetium 99m (Tc 99m) labolod radiopharma-had been administorod the prescribed radiophar. coutical for an imaging scan of her gall bladder maceutical for the proceduros. The diagnostic instead of the 8-millicurie doso proscribed in the proceduros, with one exception, were not Nuclear Modicino Department's procodures manual. considorod to be valid, and therefore of no use in their intended diagnostic function. The licensoo offorod to todo the p ocedures, although some The radiopharmaceutical was prepared and patients or their physicians elected not to have the administered by a part time technician who had studios performed again, recoked only two wooks of training in Nuclear Medicino Department procedures the previous February and had performed only two nuclear in those instancos in which a second proceduro modicino procedutos since was performod, the patient recolved additional radiation exposure. Whore the rotest was refused, the patients may have recolved a radiation exposure An NRC consultant evaluatod the medical con:,0-without benefit of a valid diagnostic procedure. quences of the incident and concludod that no However, the radiation dosos associated with biological offects should be expected from the diagnostic procodures are small. misadministration. It is estimated that the doses to the patient's bladdor and uoper largo intestino wore about 36 rads and 20 rads, respectively. NUREG-0090, Volume 13, No. 3, Report No,90-19 Medical Diagnostic Misadministration NUREG-0090, Volume 13, No. 4, Report No. 90-21 Medical Therapy Misadministration On August 14, 1990, NRC was notified by Copley Hospital that - a diagnostic misadministration involving lodino 131 had occurred at the hospital on On August 29, 1990, 86 lodine-125 soods (small August 7,1990. A G3 year-old woman undergoing scaled radiation sourcos) were permariontly 1-131 treatment for primary hypothyroidism was implanted in an 86. year old pationt at the University administered 112 microcuries instead of a routinely of Cincinnati The soods totaled 27.5 millicuries of prescribed 10 microcuries The hospital reported lodine-125. A dose of 16,000 rads was prescribed that a supply of I 131 capsules had boon ordered for the prostate gland. The soods were to be NUREG-1272, Appendix C C-8

Nonreactors-Abnorn.al Occurrences implanttd in the prostato using an ultrasonic probe boon approximately 10 feet above the concreto pad to view and position the implants for this exposure. Subsequent review by the licensee deterrninod that The radiographer attempted to crank the source most of the soods had boon implantcd too dooply back into the camera but fourd that the drive cable and had passed through the prostato into the could only be retracted a short distance because surrounding tissue. Many of the soods wore 5 to 10 the guide tube was loopod. The radiographer centimeters beyond the prostate giand. As a result, dragged the camera back by pulling on the drive the radiation dose to the prostate was no0 gible cable housing to straignton out the guide tube. After li comparod to the prescribed dose of 10,000 rads. straightening the guide tube, the radiographor The licensee estimated a dose of 15,000 rads to the retracted the cable fully, and hence thou0ht that the tissue beyond the prostate gland, consideratdy source was in the camera. The radiographor groater than the doso that would have beon romoved his two self roading pocket dosimeters and received if the seods had boon positioned as his thermoluminescent dosimotor badge. The intended. radiographor later admitted that he did this to conceal the radiation exposure he would Inter recolvo. The primary cause of the misadministration appears to be the difficulty in viewing the pros'ato area using the ultrasonic probe. The licenseo rioes not anti-The radiographor walkod up to the end of the clpato any significant effects to the patient as a source guide tube with his survey rnoter in his result of the misadministration hand, but did not refer to the instrutnent. He grasped the end of the source guide tube with his left hard and tomoved the tape which hold the i NUREG-0090, Volume 13, No,4, collimator in place with his right hand. He then Report No. 90-22 began to unscrew the source guide tubo end cap Radiation Overexposure of a Radiographer frem the source gukio tube to exchange the ond-cap for a lighter one. As he tomoved the cap, the sourco chain containing the scaled source fell out During the evening of October 5,1990, Western of the ord cap assembly onto the concrote pad. Stress, Inc., notifitd the NRC that an incident had The radiographer then dropped the source guido occurred carilor that evening while a radiographor tubo and end-cap, and left. and Ns assistant were working at a temporary job site in Bordentown, New Jorsey. The radiographic operation involved the use of a radiography device Two NRC inspectors investigated the ovont at the containing an 80.5-curie iridium-192 sealed source. Job site. Based on interviews conducted with the The licensee reported that the source became radiographer and the Corporato Radiation Safety disconnected from the drive cable and remained in Officer, the NRC inspectors estimated that the radio-the guide tube. grapher recolved a whole-body exposure of about 8.9 rom and an extremity exposure of about 1070 rom. Operations to perform 35 exposures of wolds on a tank woro planned. After cranking out the source for the sixth exposure, the radiographer heard a crash NUREG-0090, Volume 13, No. 4, ard saw that a magnetically mounted stand had Report No. 90-23 fallon and was lying on the concrete pad. The Medical Therapy Misadministration source guide tube ord-cap with the collimator had C-9 NUREG 1272, Appendix C .-. - - - - - - - -. =

AEOD Annual Report,19'O On October 10,19ro, a 60 year old female patient On October 16, the nuclear pharmacist recolved a was referred to the nuclear medicine department of request for 25 millicuries of lodine-131, but could William Beaumont Hospital for lodine-131 thyroid not find the standing order vlal. The resulting Invest-ablation therapy after undergoing a thyroidectomy igation deermined tlut the vial had been for cancer After reviewing the clinical data on the erroneously administered the previous day. patient, the authorized physician user prescribed 175 millicuries of lodine-131 to be administered orally on October 15. An NRC consultant's evaluation indicated that the misadministration should not have any signrficant medical effects on the patient. On October 15, the licensee received the patient's oral iodine-131 solution from a distributor together with a secord vlal containing 140 millicurles of NUREG-0090, Volume 13, No. 4, lodine-131. This vial is a weekly standing-order for Report No. 9424 the hospital and is used as needed during the week. Radiation Overexposure of a Radiographer The two vlais were assayed by a technologist. After On November 26, 1990 Tumbleweed X Ray the assay, the technologist placed both vials side by Company notified the NRC that on November 12, side in the fume hood located in the nuclear 1990, a radiographer's assistant may have sustained pharmacy. Both were still in their original leaded a possible radiation overexposure to his right hand shleids and labeled as to their contents. at a temporary job site in Burns Flat, Oklahoma. The licenseo stated that it was not informed of the incident by the radiographer until the morning of The authorized physician-user was ready to November 25,1990, because the radiographer did administer the iodine-131 to the patient, and called not thinx an overexposure had occurred until the for the material. Since the technologist who had assistant radiographer's right hand became rod and prepared the dosage was not available, another his fingers began to swell. technologist went to the pharmacy to obtain the radiopharma ceutical. T he ad minist ering t echnologist picked up both vials, assuming they were to be On the day of the incident, the radiographer ard his administered to the patient. The technologist did not assistant were working with a radiography device review the labels on the containers, assuming they that contained a 49-curic iridium 192 scaled source, were the proper doses The technoiogist also did An NRC inspector investigated the incident. not consider the administration of more than one vial to be unusual since this was a common occur-rence at this facility. The radiographer and his assistant were performing radiographic exposures of welds on a 48 inch. diarneter tank at a fabrication shop. After the sixth After reviewing the dosage record, the authorlad exposure, the radiographer Icft. While the radio-physician instructed the technologist to administer grapher was away, the assistant set up the seventh the dose to the patient. The authorized user did not exposure and cranked out the source. The assistant review the labeling on the containers, believing that had turned the crank about two or three turns when since the patient's unit dose record was complete he saw that the magnetica"y mounted stand that and Indicated a dosage of 180 millicuries, the two held the guide tube near the tank exterior had fallen. vials were the proper ones for administration NUREG 1272, Appendix C C 10

l Nontoactors-Abnormal Occurrences The assic' ant radiographer's alarming personnel fingers, ard that the source had to be directly dosimeter (chirpor) had alarmod loudly when the beneath the point graspod. This information may guide tubo had fallen. The assistant stated that he indicate that the assistant radiographor mistakonly froze for about 5 seconds, thoo be cranked the cranked the source out, instead of in, when the source back to the shleided poshion. The assistant's incident first occurred. chlrper had quit alarming, so he thought the source was in the shielded position in the radiography device. The assistant radiographer stated that he From roenactments, clinical observations, and failed to pick up and usa his survey instrument to calculations, the dose _to the assistant radio-survey the radiography device and the source guido grapher's hand was estimatod by the NRC to be tube because his chirpor was not alarming. The betwoon 1500103000 rom. The whole body dose to chirper had been dropped a couplo of timos that the assistant, as measurod by his thermolumi-night and upon subsequent testing was found to be nescent dosimotor, was 365 millirem. Blood samplos malfunctioning due to a shorted ground wire. were taken from the assistant for cytogenetic tests; instead, the assistant radiographer walked over to the results indicated an equivalent wholotody the tank and repositionod the magnetic stand and exposure of less than 10 rom. source guide tubo. After the assistant radiographer correctly positioned the guide tube with his right hand, he retumed to the crank handle to proceed On November 29.1990, the NRC laspector noted with the exposure. that the assistant's thumb, index, and middle fingers woro sovercly blistered ard swollen. On this date the assistant was admitted to a burn contor in When he performed this exposure, he noted that his Oklahoma City, Oklahorr,a, for modical care. The chirper did not alarm when the source was cranked assistant romalnod in the hospital for approximately out. Because of this, he looked at his pocket two wooks, and during that period had a skin graft dosimeter and noticed that it was off scale (greator performed on his index finger, On January 22,1991, than 200 millirem). At about the same timo, the the physician contacted NRC arxl stated that the radiographer retumod and the assistant told him assistant's middio finger and thumb appeared to be what had happened and that his pocket dosimeter healing and that the index fingor was gratted as a had gone off scale. The assistant - told the result of lesions that were not healing. The physician radiographor that no did not think that he had also stated that the assistant would remain under received an overexposure, but that he thought his his caro, pocket dosimeter was off scale because he had bumpod it earticr. The radiographer and his assistant continued to work and did not Inform the NUREG-0090, Volume 13, No. 4, Radiation Safoty Officer of the incident until the Report No. 90 25 assistant's hand showed clinical signs of a radiation Medical Diagnostic Misadministration - injury. - On November 26,1990, a patient at the Votorans The radiation injuries that the assistant radiographer Administration Medical Centor in San Diogo who sustained to his hand indicated that he grasped the was scheduled for the administration of 5 millicuries gulde tube with his thumb, index, and middle ofindium 1111abolod anti-CEA monoclonalantibody C-11 NUREG 1272, Appendix C e _ _ _. - ~,, -

i AEOD Annual Roport,1990 for diagnostic imaging of coloroctal cancer was The patient was immodlatoly hospitalized and mistakenly administered 1G3 millicuries of isolated (the standard practice for thyroid ablation technetium.99m portochnetate, patients). The patient was discharged on November 5,1989. A technical assistant erroneously pickod up a syringe containing the technetium-99m pertech-The patient's family was contactod and a bloassay notate and gave it to the physician. The physiclan was performod to determino the thyroid body fallod to positively identify the labol on the syringo burden of each family member. The thyroid burdens before injecting the contents of the syringo into the were above the action levol for radiation workers patient. (0.4 microcurio) but the level was not contidorod a serious health threat to any family member. J The error was discovered by the licensee within minutes after the misadministration and the patient A hospital employee and an ARRA representatNe was administered 10 drops of iodide and 1 gram of surveyed and decontaminated the patient's house. perchlorate to block and flush the thyroid gland Wipo tests were used to verify the efficiency of the respectively. decontamination. The patient was placed in an isolated room normally The hospital staff did not assay the dose in the dose used for therapy for two days. The patient was calibrator before administering it, dk1 not compare scanned approximately 30 hours efter the misad-the lodine 131 dose label with the physician's order, miristration and the thyroid pland shewed no and did not maintain adoquate records of incoming elevated radioactMty. A small rt sidual amount of radiopharmaceuticals. technetium-99m was detected in the bladder. Following the scan, the patient was noted to be clinically unchangoc and was discharged from the Syncor International, Inc., the radiopharmacy that licensee's modical center. dispensod the dose, did not record the type of intended procedure. NUREG-0090, Volume 13, No. 2, Report No. AS901 NUREG-0090, Volume 13, No. 3, Medical Diagnostic Misadministration Report No. AS90-2 Medical Therapy Misadministration On November 1,1989, a patient scheduled for the administration of 100 microcurio capsules of On April 19, 1990. at Yuma Regional Medical lodine-123 for a diagnostic thyroid scan at Desort Center, a patient's uterine tumor was implanted with Samaritan Hospital was mistakenly administered a 224 tridium-192 seeds using 32 trochars (a sharp, therapeutic dose of 100 millicuries of iodine-131 and pointed surgical instrument fitted with a hollow sent home for 24 hours until the normal imaging tube), each containing 7 soods on a ribbon. The was scheduled, proscribed dose was about 2000 rads A problem was noted with snagging of the ribbon in one trochar; five seeds were stripped from the trochar When the patient retumed on November 2, the when an attempt was being made to remove both imaging camera flooded out, which indicated a the trochar and the seeds. The trochar had inad. large overdose. The hospital immediately notified vertently been placed in a necrotic cavity within the the Arizona Radiation Regulatory Agency (ARRA). NUREG 1272, Appendix C C-12

i i i Nonroactors-Abnorrnal Occurrences j r { tumor, permitting the soods to ' pay out' into the The five soods were luft in the necrotic tumor cavity rather than being stopped by tissuo. center. Those soods, from the time of emplacement until total decay, would deliver e dose considerably in excess of the proscrlbod dose. However, a '{ An unsuccessful attempt was made to tomove the modical consultant stated that the patient's poor five stripped soods during removat of the other prognosis from her illness outweighed any term soods. When the trochar that had contained the from additional radiation (Tho patient subsoquently l snagged ribbon was tomovod, it was discovorod died from her lilnots.) that the tip of the trochar had boon bent, presum-l ably by the stony hardness of tho tumor. The trochar was not bent before it was inserted. I e l 1 i I I i i I 1 i I t l 1 = a } i i i t l C-13 NUREG-1272, Appendix C - l l - _...._ -_..,.-.~.-. ___.._._,_ _ _ _ _,, _ _. _. - _, - _,.. _ _ _, _. - - - - -. __ _, _. O

Appendix D Reports issued From 1981 Through 1990 (Nonroactors) i

- - _ - - = _ - = - -. - _ - _ Nonreactor Reports issued From 1981 Through 1990 Nonreactor Reports issued in 1990 Engineering 9 valuations Date Title No. Author 06/90 Report on 1989 Nonroactor Events K. Black 06/90 Modical Misadministration Report-Medical H. Karaglannis Misadministrations Reported to NRC From January 1989 Through Docornber 1989 Nonreactor Reports issued in 1989 Engineering Evaluations Date Title No. Author 06/89 Use of Radioactiv6 lodino for infrequent N901 H. Karagiannis Medical Studios and Thoso Performed Under an FDA Investigational Exemption of a Now Drug (IND) 06/89 Report on 1988 Nontoactor Events K. Black 06/89 Medical Misadministra' ion Report-Moolcal H. Karagiannis Misadministrations Reported to NRC From January 1988 Through Dacomber 1988 05/89 Review of Therapy Mieadministrations T908 K. Black That involved Mutilplo Patients and the Use of Computer Programs Nonreactor Reports issued in 1988 Special Study Reports Date Title No. Author 09/88 Review of Events at Largo Pool Type S807 E. Trager !rradiators (NUREG 1345, March 1989) .:l :::::!:b"::: A:12'r' lNin::l l:Mi::nllH:",2:::llM::l: l'A'at'a,73".ttfa' aWW.0;12 k'4ti',00%"$,t!"'5 M D-1 NUREG 1272, Appendix D

AEOD Annual R: port,1990 Nonreactor Reports issued in 1988 (cont.) Engineering Evaluations Date Title No. Author 10/88 Report on 1987 Nonreactor Events N801 K Black 10/88 Medical Misadministrations Reported to NRC N802 S. Pettijohn for the Period January Through December 1987 Nonreactor Reports issued in 1987 Special Study Reports Date Title No. Author 10/87 Radiography Overexposure Events involving S703 S. Pettijohn Industrial Field Radiography Engineering Evaluations Date Title No. Author 01/87 Diagnostic Misadministrations involving the N701

3. Pettijohn Administration of Millicurie Arnounts of lodine 131 03/87 Diagnostic Misadministrations Reported to N702 S Pettijohn NRC for the Period January 1986 Through December 1986 Technical Review Reports Date Title No.

Author 03/87 Report on 1986 Nonreactor Events N703 K. Black 11/87 Review of Data on Telethorapy Misadmlnistrations T711 S. Pettijohn Reported to the State of New York That Were the Title of PNO-l 87 74A 12/87 Distribution of information Notices and Other T714 S. Pettijohn ' Mass Malling" Information to Licensees That Have Users at Locations Remote From the Headquarters Locations NUREG 1272, Appendix D D2

Nontc::ctors-R ports, 1981 1990 Nonreactor Reports issued in 1986 Case Studies Date Title No. Author 08/86 Rupture of an todine 125 Brachytherapy C001 S. Pettijohn Source at the UnNersity of Cincinnati Modical Centor Engineering Evaluations Date Title No. Author 06/86 Report on 1985 Nonroactor Events and N001 K. Black FNe Year Assessment for 19811985 Reports 00/06 Medical Misadministrations Reported for NG02 S. Pettijohn 1985 and FNo Year Assessment of 1981 1985 Reports Nonreactor Reports issued in 1985 Case Studies Date Title N o. Author 12/L Therapy Misadministrations Reported to NRC C505 S. Pettijohn Pursuant to 10 CFR 35.42 Engineering Evaluations Date Title No. Author 05/85 Summary of the Nonreactor Event Report N501 K. Black Data Base for the Period January-June 1984 06/85 Summary of the Nonroactor Event Report N502 K. Black Data Base for the Period July-Docomber 1984 07/85 Report on Medical Misadministrations for N503 S. Pettijohn January-Docomber 1984 D-3 NUREG-1272. Appendix D

_. _ = _ - = AEOD Annual R3 pod,1990 Nonreactor Reports Iseued in 1984 Case Studies Date Title No. Author 09/84 Breaching of the Encapsulation of Scaled Well-C405 S. Pettijohn Logging Sources 05/84 Report on Medical Misadministrations for January N204D S. Pettijohn Through June 1983 06/84 Nonreactor Event Report Database for the N401 K. Black Period July-December 1983 06/84 Events involving Undetected Unavailability N432 E. Trager of the Turbine-Driven Auxiliary Feedwater Train 07/84 Report on Medical Misadministrations for N403 S. Pettijohn July-December 1983 Nonreactor Reports issued in 1983 Engineering Evaluations and Technical Reviews Date Title N o. Author 01/83 Nonreactor Event Report Database for the N209A E. Trager Period Januarydune 1982 03/83 1125/l-131 Effluent Releases by Material N301 S. Pettijohn Licensees 36/83 Mound Laboratory Fabricated PuBe Sources N302 K. Black 06/83 Americium Contamination Resulting From N303 K. Black i Rupture of Well Logging Sources j 06/83 Nonreactor Event Report Database From N2098 K. Black July through December 1982 i 07/83 Americium-241 Sources N304 07/83 Report on Medicti Misadministrations for N204C S. Pettijohn January 1981 December 1982 NUREG-1272, Appendtx D D4

- - _ ~ _ -. _. _ _ _ _ Nonreactors-R ports, 1981 1990 Nontcactor Reports issued in 1983 (cont.) Engineering Evaluations and Technical Reviews (cont.) Date Title No. Author 12/83 Potentially Leaking Americium 241 Jources N306 S. Pettijohn Manufactured by Arnersham Corporation 12/83 Nonreactor Event Report Database for the N307 K. Black Period January-June 1983 03/83 Internal Exposure to Am 241 NT301 K. Black 04/83 Kay Ray, Inc., Reports of Suspected Leaking NT302 S. Pettijohn Sealed Sources Manufactured by General Radioisotope Products 08/83 Possession of Unauthorized Sealed NT303 S. Pettijohn Source / Exposure Device Combinations by MidCon Inspection Services, Inc. Nonreactor Reports issued in 1982 Engineering Evaluations Date Title No. Author 02/82 Report on Medical Misadministrations for the N201 S. Pettijohn Period November 10,1980-September 30,1981 01/82 Buildup of Uranium-Bearing Sludge in Waste Tanks N202 K Black 02/82 Lost Plutonium-238 Source N203 K Black 03/82 Report on Medical Misadministrations for CY 1981 N204 S. Pettijohn 04/82 Preliminary AEOD Review of lodine-125 N205 E. Trager Sealed Source Leakage incidents 05/82 Ebertino Instrument Corporation Part 21 Report N206 K. Black 05/82 AEOD Review of lodine-125 Scaled Source N207 E. Trager Leakage Incidents 08/82 Potentially Leaking Plutonium Beryllium N208 S. Pettijohn Neutron Sources D-5 NUREG-1272, Appendix D

AEOD Annual Roport,1990 Nonreactor Reports issued in 1982 (cont.) Engineering Evaluations (cont.) Date Title No. Author 08/82 A Summary of the Nonreactor Event Report N209 K Black Data Base for 1981 11/82 Leaking Hoses on Self Contained Breathing N210 K. Black Apparatus (SCBA) Manufactured by MSA Nonreactor Reports issued in 1981 Engineering Evaluations Date Title No. Author 03/81 interim Report on Brown Boveri Betatron N101 E. Trager Calibration Check Source 03/81 Irradiator incident at an Agreement State N102 K Black Facility (Becton-Dickinson, Broken Bow, Nebraska 04/81 interim Report on the October 1980 Fire N103 E. Trager at the Ucensee's Sweetwater Uranium Mill 04/81 Interim Report on the January 2,1981 Fire N104 E. Trager at the Atlas Uranium Mill 05/81 Interim Report on lallings impoundment N105 E. Trager Uner Failure at the Sweetwater Uranium Mill 08/81 Review of Reports of Leaking Radioactive Sources N106 E. Trager 12/81 Engineering Evaluation of Fire Protection at N107 E. Trager Nonreactor Facilities 12/81 Notes on AEOD Review of Emissions From Tritium N108 E. Trager Manufacturing and Distribution Uconsees i NUREG-1272, Appendix D D-6

e Appendix E Status of AEOD Recommendations (Nonreactors)

Status of AEOD flocommendations The Office for Analysis and Evaluation of Operational Data (AEOD) tracking system onsures that all formal AEOD recommendations are trackod until resolution At this time, no issues involving AEOD recommerxfations are unresolved that warrant the attention of the Exocutivo Director for Operations. Formal recommendations are tracind and listed in this section. Additionally, actions based on AEOD suggestions contained in ongineering evaluations and special reports are routinoly implomonted by NRC program offices. These AEOD suggestions are not formally tracked or closed out by AEOD. AEOD Recommendation Tracking System Outstanding Recommendations

• Recommendation Source:

Case Study AEOD/C505 Responsibio AEOD Engineer: K Black (Author. S. Pettijohn) Title or

Subject:

' Therapy Misadministrations Reported to the NRC Porsuant to 10 CFR 35.42' Recommendation 4: In addition, to the extent that the NRC implements Recommendation 3, the action should be mado an item of compatibility for Agreomont States. Responsible Office /Div/Br Contact Priority GPA/SLITP V. Millor N/A l ( Status: Action will be taken on Rocommendation 4 after action is taken on Recommendation 3, which is part of the rulemaking on Quality Assuranco in Radiation Therapy.

• rbe hurnbef Of thf FPCommendat!On in the $dme 85 the fWmber of the OrgiNtl Cabe Stikdy i

E-1 NUREG 1272, Appendix E

[ i Appendix F Status of NRC Staff Actions for Event investigated by incident investigation Team (Amersham Corporation,1990) 5 I I -.--+,__.,-+,-r r--.e-., -,o y sy-,,.....-,, -

Status of NRC Staff Actions for the Event Investigated by the incident investigation Team at the Amersham Corporation in 1990 in accordance with NRC Manual Chapter 05t3, such as authorization for restart, plant inspections,

• NRC incident Investigation Program,' dated or possible enforcement Actions. These actMties May 14, 1990, upon receipt of an Incident are expected to be definod and implemented Investigation Team (llT) report, the Executive through the normal or0anizational structure and Director for Operations (EDO) shall identify and procodures.

assign NRC office responsibility for generic and plant-specific Actions resulting from the investigation This appendix provides a writton disposition and/or that are safety significant and warrant additional status, along with appropriate references, for each attention or action. Office directors designated by of the NRC staff action hems that the EDO assigned the EDO as having responsibility for resolving issues to the various NRC offices associated whh the llT l or concerns are responsible for providing written report on the 1990 ovent at Amersham Corporation. i status reports on the disposition of assigned Actions. In addition, followup Actions associated For each action hom, the entry for its

• Disposition
• with the 11( report do not necessarily include all indicatos whether action for the he.n is resolved or licensee Actions, nor do they cover NRC staff ongoing. For ongoing action items, the NRC office activhlos associated with normal event followup assigned the action item is designated.

F.1 NUREG-1272, Appendix F

AEOD Annual Report,1990 AEOD llT Action Tracking System Source: ilT Report on Amersham Event of March 9,1990 (Reference 1) ltem In: Action: Provide assurance that Korean authorttles are aware of this event and that they have been requested to initiate action to ensure that Korean shlppers will physically verify contents of source changers before shipping to the United States. (Responsible Office: Governmental and Public Affairs (GPA)) Disposition: Resolved. Korean authorities were notified by cable (through the United States embassy in Seoul) the same day the incident was reported to NRC headquarters. In addition, copies of the llT report (Reference 1) were forwarded to the Korean authorities the day the report was made publicly available. A copy of the Koreans' final report of the investigation was sont to NRC in September 1990, and it Indicated that Korea had procedures for handling, storing, and disposing of radioactive waste materials, but that these procedures were violated by the Korean user. The Kon Torities took additional steps to reiterate their requirements to all users of radioactive materials. Item ib: Action: Provide assurance that other countries that retum source changers to the United States are aware of this event. (Responsible Office: GPA) Disposition: Resolved. On August 4,1990, a cable summarizing the Amersham incident was sent through the Department of State to the 54 countries that import United States radionuclide sources as well as to the five other countries that export them and to the Intemational Atomic Energy Agency. In addition, copies of the llT report (Refarence 1) were also sent to all exporting countries and offered to the importing countries upon request. NUREG-1272, Appendix F F-2 i 4 m m 1

Nontoactors-Staff Actions AEOD llT Action Tracking System item 2: Action: Assure that all NRC and Agrooment State licensees that export and import radioactive materials are made aware of this event for application of controls to their programs, as necessary, and assure that their foreign clients and customers are adequately informed of conditions and constraints relative to the importation of radioactive materials into the United States. Evaluate the practicality of requiring manufacturers to imprint the source capsulo with a manufacturer's identification mark and/or serial number. (Responsiblo Office: GPA and Nucioar Material Safety and Safeguards (NMSS)) Disposition: Rosolved. On July 20,1990, the NRC sont letters to principal NRC licensees that export and import radioactive materials, informing them of the Amersham incident. An NRC information notice was subsequently published and distributed to all licensees on September 4,1990 (Reference 2). On July 20,1990, the NRC sent letters to source manufacturers requesting their views on the practicality of imprinting source capsules with the manufacturer's identification and model numbor. Although the respondents supported the concpt of labeling sources, certain sources are too small to allow imprinting of this information. Further, the NRC staff was concemed that labeling radiography sources with vendor information may decrease the offectiveness of the regulatory requirements to have the wording

• Danger Radioactive" applied to the source by reducing the size of the wording. Thus, the staff concluded that it was neither practical nor desirable to require vendor-identifying information on the radiography scaled sources.

Item 3: Action: Infoim members of the public of the outcome of this event, and the results of the NRC investigation. (Responsible Office: GPA) Disposition: Resolved. The NRC issued a press release describing the Amersham incident on March 9,1990, and sent copies of the summary section of the llT report (Reference 1) to interested media in the New England region. Item 4: Action: Inform all individuals who had the potential for measurable exposure to the source of the NRC's exposure evaluation of their specific case, including discussion of the cytogenetic evaluation results. (Responsible Office: NMSS) F-3 NOREG-1272, Appendix F

y AEOD Annual Report,1990 AEOD llT Action Tracking System Disposition: Resolved. During March through June 1990, Oak Ridge Associated Universities (ORAU) contacted the medical officers of the transportation companlos involved in the Amersham incident and provided them with cytogenetic estimates of potential radiation effects to their exposed personnel. Transportation company medical officers were to transmit and explain the ORAU estimaios to the transportation company employees. Item 5: Action: Evaluate the need to amend DOT and NRC regulations relative to the performance of independent verification of the quality of radioactive material shipments imported into the United States. (Responsible Office: NMSS) Disposition: Resolved. Shipments in transit are primarily covered by DOT regulations. On August 13,1990, the NRC requested that DOT provide comments on the need for a requirement for carriers or shipping agents to provide monitoring of shipments during transport. Although a formal response from DOT is not expected until early 1991, followup discussions indicated that the DOT staff believes that current regulations are adequate and that DOT probably will not initiate any rule changes. Item 6: Action: Evaluate whether NRC and DOT regulations should be amended to include requirements to report the receipt of shipments of radioactive materials the.t were improperly prepared, labeled, identified, or classified, or had improper contents. (Responsible Office: NMSS) Disposition: Ongoing. On August 13,1990, the NRC requested that DOT provide comments on the need for a requirement for consignees to report improperly labeled or prepared packages upon receipt. A formal response from DOT is not expected until early 1991. Tho staff performed an evaluation of NRC and DOT reporting requirements (Reference 3) l and concluded that requiring lictnsees to report all mislabeled or misidentified packages would require both the licensees and NRC staffs to expend significant resources in reporting and responding to problems that are of little or no safety concern. However, the i staN also concluded that the NRC should be informed and should respond to any situation similar to the Amersham incident. The NRC staff determined that because the new 10 CFR Part 20 requirements will only apply to labeled or damaged packages, the previous situation in which Amersham received a cropped source in a packag ' thought to be empty may not NUREG 1272, Appendix F F-4 l l

9 Nonreactors--Staff Actions AEOD llT Action Tracking System be covered. The NMSS staff will recommend to the Office of Nuclear Regulatory Research that Section 20.906 of 10 CFR Part 20 be amended to require licens.ees to nottfy the NRC If the licensee determines that it has received an unlabeled package containing radioactive materials that should have been labeled in accordance with DOT requirements. Item 7s: Action: Verify that Amersham has reviewed instructions to foreign shippers relative to DOT requirements to assure that the directions aee complete and accurate. (Responsible Office: Region I (RI)) Disposition: Resolved. RI notified Amersham of the nood to improve its instructions issued ta foreign shippert. On September 13,1990, the NRC conducted a routine inspection and found that Amersham had taken appropriate corrective Actions by Issuing revised Instructions to all users. Item 7b: Action: Assure that other NRC and Agreement f, tate licensees that import radioactive materials are informed of the requirements of 49 CFR 171.12. (Responsible Office: NMSS and GPA) Disposition: Resolved. NRC Information Notice 90 56 (Reference 2), issued on September 4,1990, informed licensees of the requirements of 49 CFR 171.12. Item 8: Action: Initiate action to assure that each NRC and Agreement State licensee that imports (expects to have retumed) empty source changers or other c'3 vices that were originally supplied to foreign entitles for the transport of radioactive sources (such as radiography exposure devices) provide its respective customers with instructions that direct a physical determination be rede that such devices are empty upon return to the United States. (Responsible Office: NMSS and GPA) F-5 NUREG-1272, Appervilx F

AEOD Annual Rrport,1990 AEOD llT Action Tracking System Disposition: Resolved. NRC Information Notice 90-56 (Reference 2), issued on September 4,199], informed licensees of the need to physically check empty containers before their return shipment. On June 14,1990, the NRC requested that all Agreemerit States have their licensees provide their foreign customers with shipping instructions that direct them to make a physical determination that devices are empty before returning them to the United States. Item 9: Action: Meet with DOT and determine the purpose and expectation of actions on the part of forwarding agents at the place of United States entry, relative to shipments of radioactive materials, whether such agents are informed of the pertinent DOT requirements, arx' " hether such requirements are realistic and important relative to the handling of radioactive material shipments, and should be enforced (Responsible Office: NMSS) Disposition: Ongoing. pending completion of the DOT investigation. On August 13,1990, the NRC requested tha' ')OT provide comments on this issue. DOT is still reviewing the Amersham incident, and the investigation is not expected to be completed until mid-1991. NRC licensees were informed of the need to comply with DOT Import /expoit requirements in NRC Inforrnation Notice 90 56 (Reference 2). If appropriate, 1 NRC will notify licensees of the DOT investigation findings in a supplemental information notice. Item 9b: Action: Pending the results of action hem 9a above, initiate action to assure that Amersham has taken appropriate corrective measures relative to the completeness and accuracy o! information provided to forwarding agents. (Responsible Office: RI) Disposition: Ongoing, pending completion of the DOT investigation. Upon completion of the DOT investigation, NMSS and RI will follow up, as appropriate, to ensure compliance by Amersham. NUREG-1272, Appendix F F4

Nonreactortr-Staff Actions AEOD llT Action Tracking System ftem 10: Action: No action required item 11: Action: Meet with DOT and determei j the conditions of use that portain to the utilization of NRC-certified Type B packages for the shipment of Type A quantitles of radioactive rnatoricts, and initiate action to amend DOT and NRC requirements, as necessary. For example, could 2 Model 500-SU source changers, which NRC certified as an effectiva shipping container for Type B quantitles when used in conformance with the Certificate of Compilance, be used to ship Type A quantitles of radiographic sources that were not specifically authorized for the package in terms of design or configuration, as long as all other pertinent DOT speerications were adequately satisfied? (Responsible Office: NMSS) Disposition: Resolved. On August 13,1990, the NRC requested that DOT provide comments on the use of NRC-certified Type B packages for shipping Type A quantities of radioactive material. The NRC and DOT staffs agreed on conditions for which Type B packages are acceptable for Type A shipments. NRC Information Notice 90-82 (Reference 5), issued on December 31,1990, provided licensees information on the requirements for use of NRC-approved transport packages for shipment of Type A quantitles of radioactive materials. l.em 12: Action: Initiate actior' 'o ensure that Amen %m's source changers are brought into compilance with the NRC Cer ctfe of Compliance. (Responsible Office: RI) Disposition: Resolved. On April 27,1990, Amersham submitted a request to NRC to amend the Certificate of Compliance to describe both types and styles of Model SU-500 source changers. On September 13,1990, RI verified that the source change,s in use are in accordance with the propot.ed amendmont to the Certificate of Compliance. F-7 NUREG-1272, Appendix F

AEOD Annual Report,1990 AEOD llT Action Tracking System

References:

1. NUREG-1405, " inadvertent Shipment of a Radiographic Source from Korea to Amersham Corporation, Burlington, Massachusetts," dated May 1990. 2. NRC Information Notice 90-56, " inadvertent Shipment of a Radioactive Source in a Container Thought To Be Empty,' dated September 4,1990. \\ 3. Memorandum from J. Glenn to J. Hickey (NRC), ' Evaluation of NRC and DOT Reporting 1 Requirements; NMSS Followup to inadvertent Shipment of a Radiographic Source from Korea to Amersham Corporation (NUREG-1405)," dated October 31,1990. 4. Memorandum from R. Bernero to E. Beckjord (NRC), " Request for Rulemakin0-Amendment to 10 CFR 20.906, Procedures for ReceMng and Opening Packages," dated February 25,1991. 5. NRC Information Notice 90-82, ' Requirements for Use of Nuclear Regulatory Commission (NRC) Approved Transport PacLages for Shipment of Type A Quantitles of Radioactive Materials,' dated December 31,1990. NUREG-1272, Appendix F F-8

NRC F-ORM 3% U S. NUCLr AR HE GULAT OHV COMM$SION

1. Bl. PORT f 4UMht it

( Assignwi t,y NHC, j$1 vol, i I p.agt Lupp, hev, ed A edom f 4um-NRCM 1102, ""

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m mz b'BLIOGRAPHIC DATA SHEET NURiiG-1272 see instructions on ine remei 2 ll1Lt. AND SUbilILL 3 DA T L ht PUH I PUDLISHL D Office for Analysis and I!"aluation of Operational Data uoy7n l yc n I 1990 Annual Report - Nonreactors July 1991

4. f IN OR GRANT NUMBEH 6.AUlrK>M(N 0.1 YPE Of HLPOH1 Annual summary of regulatory activities for nonrecctors

7. PE FOOD CovlHED Onctusive Dates)

CY 1990

6. PLhFORMING OHGANIZ ATION - NAML AND ADDRE SS Of NHC, provide DMsion, O?t ce or Reg,on, U S Neear Hegolatory ComrTnssion, and malling acxtress; if contractor, provkje name and malling address )

Office for Analysis and Evaluation of Operational Data U.S. Nucicar Regulatory Commission Washing (on, DC 20555

9. 6PONSORING ORGANIZA TION - NAME AND ADDRESS Of NHC, type

• Some as atnve ; it contractor, provde NHC Division. 01tice or Hegon, U. S. Nuclear Regulatory Commmston, and mailtng address }

Same as in item 8

10. SUPPLEMENT AHY NOIl S

11. ABSTRACT (200 words or less)

The annual report of the U.S. Nuclear Regulatory Commission's Office for Analysis and livaluation of Operational Data (Ar!OD)is devoted to the activities performed during 1990. The report is published in two separate parts. NUREC 1272, Vol. 5, No.1, covers power reactors and presents an overview of the operating aperience of the nuclear power industry from the NRC perspective, ucluding comments about the trends of some key performance measures. The report also includes the principal findings and issues identified in A!!OD studies over the past year and summarizes information from such sources as licensee event reports, diagnostic evaluations, and reports to the NRC's Operations Center. The reports contain a discussion of the incident Investigation Team program and sum-marize the incident Investigation Team and Augmented Inspection Team reports for that group of licensees. NUREG-1272, Vol. 5, No. 2, covers nonreactors and presents a review of the events and concerns during 1990 asso-ciated with the use of licensed material in nonreactor applications, such as personnel overexposures and medical misadministrations. Each volume contains a list cf the Ai!OD reports issued for 1980-1989.

13. AVAILABILITY ST ATEMf.NT

12. KEY WOADSIDESCR>PTons (List words or phrases that will assnit researchers en locating the report )

Unlimited

14. Fr.CUHITY Cl ASS *lCATION nuclear plants,

engineered safety features operatmg expenence new plant expenence Unclassified abnormal occurrences IIT staff action status (T h '" P"'O significant events AEOD recommendations reactor trips AI!OD report Ir.ing Unclassified a NUMut n of P^ots performance indicators it H UCI NRC FORM Th (249)

THIS DOCUMENT WAS PRINTED USING RECYCLED PAPER

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