ML20138P193

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Forwards IE Circular 78-10, Control of Sealed Sources Used in Radiation Therapy. W/1978 List of IE Circulars
ML20138P193
Person / Time
Issue date: 06/14/1978
From: Seyfrit K
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
To:
FITZSIMONS ARMY MEDICAL CENTER, AURORA, CO
Shared Package
ML17354B291 List:
References
FOIA-96-395 NUDOCS 9703040083
Download: ML20138P193 (5)
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Text

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'f -x n O 4 U.*'lTED STATES 3

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, NUCLEAR REGULATORY COMMISSION C , ya o REGION IV j 611 RYAN PLAZA DRIVE, SUITE 1000

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  • -.** ' June 14, 1978 i

i Department of the Army Fitzsimons Army Medical Center Denver, Colorado 80240 70,' Gentlemen:

The enclosed Circular 78-10, is forwarded to you for_ infonnation. If-there are any questions related to your understanding of the suggested

,4 actions, please contact this office, f

  • Sincerely, ,

~

[Y K. V. Seyfrit Director

Enclosure:

1. 'IE Circular flo. 78-10
2. List of IE Circular

' Issued in 1978 E

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I i l 9703040083 970220 PDR- FOIA OLADE96-395 PDR g

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/ UNITED STATES NUCLEAR REGULATORY COMMISSION OFFICE OF INSPECTION AND ENFORCEMENT WASHINGTON, D. C. 20555 IE Circular No. 78-10 Date: June 14, 1978 Page 1 of 2 CONTROL OF SEALED SOURCES USED IN RADIATION THERAPY ,

Over the past several months various incidents have been reported to the Nuclear Regulatory Commission (NRC) which involved the inadequate control and accounting of NRC-licensed byproduct material used in the topical, interstitial or intracavitary treatment of cancer. We request that you inform all individuals in your organization involved with the use of sealed sources of byproduct material for therapy about this circular.

Following are examples of incidents reported to the NRC:

. A patient while undergoing radiation therapy for cancer had twelve iridium-192 seeds containing approximately 0.5 mci each implanted but only eight removed at the desired tine. The remaining four iridium seeds were noticed missing about three months later. Licensee follow-up revealed that the remaining four iridium seeds were still in the patient.

. A patient receiving radiation therapy for cervical cancer had two radium applicators implanted. Although both were scheduled to be removed two days later, only one was removed at that time.

The second applicator was noticed missing about one month later.

Licensee follow-up revealed that the radium loaded applicator was still in the patient.

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. An applicator containing two 79 mci cesiun-137 sources was I removed from a patient and returned to the storage room, but I not immediately dismantled. A routine inventory two weeks later revealed that one of the two sources had been returned to its proper storage place but the other was missing. The hospital was unable to locate the missing source or determine who had disassembled the applicator.

. Another hospital reported that a 40 mci cesium-137 uterine implant was dislodged from a patient and only after an extensive search was it found in a laundry room floor drain trench.

NRC recommends that the following actions be considered by each licensee authorized to use sealed sources in topical, interstitial or intracavitary

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' 1-IE Circular No. 78-10

. Page 2 of 2 treatment of cancer. These recommended actions may already be a part  ;

of your program and may be conditions of your license. If you change

'; any procedures which are conditions of your license, you must notify the Radioisotope Licensing Branch of NRC so.that your license may be 4

amended.

1. . Review the adequacy of your procedures for the use and control of sealed sources in therapy. Such procedures should include:
a. Written instructions covering all phases of use and control.

, These instructions should be posted and/or distributed to

all individuals involved with the use of therapeutic sources. .
b. Establishment and maintenance of a log containing the physical location of each source. This log should contain a record by '
date of sources received, removed from storage, in use, and '

i removed from patients. For sources being used in ' patients, the log should state the name of the responsible physician and the patient. When sources are removed from a patient, the

sources'should be immediately counted and a comparison made with the log entry when the sources were removed from storage to assure that all sources are accounted for.
c. Requirements for survey of each patient using proper radiation detection instrumentation when radioactive sources are implanted and removed. In addition, the patient's room, the linen, and material leaving the room should be surveyed during  ;

i treatment for sources that may become dislodged.

4 Requirements for the performance of periodic inventories of L d.

all sealed radioactive' sources. These inventories should be performed on a schedule to assure control of the sealed

! sources but on a schedule no less than that required by your i, license and/or 10 CFR Part 35.14(b)(5)(v).

e. Suitable control and' restriction of access to, and provisions for security of, radioactive sources.

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2. Assure that periodic audits or other management controls are exercised to ensure that procedures are followed.

, No written response to this circular is required. If you require additional information regarding this matter, contact the Fuel Facility and Materials Safety Branch of the appropriate NRC Regional Office.

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a .

t IE Circular No. 78-10 June 14, 1978

' LISTING OF IE CIRCULARS ISSUED IN 1978 Ci rcular Subject First Date Issued To No. Of Issue 78-01 Loss of Well Logging 4/5/78 All Holders of I Source Well Logging Source '

Licenses 78-02 Proper Lubricating 4/20/78 All Holders of ,

Oil for Terry Reactor Operating i Turbines Licenses (0L) or l

Construction Permits (CP) 78-03 Packaging Greater 5/12/78 All Holders of Than Type A Reactor Operator Quantities of Low Licenses (OL),

Specific Activity Construction Radioactive Material Permits (CP), Fuel for Transport Cycle, Priority I Material and Waste Disposal Licenses t

78-04 Installation Error 5/15/78 All Holders of  ;

That Could Prevent Reactor Operating Closing of Fire Licenses (0L) or Doors Construction Permits (CP) 78-05 Inadvertent Safety 5/23/78 All Holders of Injection During Reactor Operating Cooldown Licenses (OL) or Construction Permits (CP) 78-06 -

Potential Common 5/25/78 All Holders of Mode Flooding of Reactor Operating ECCS Equipment Licenses (0L) or Rooms at BWR Construction Facilities Permits (CP) 78-07 Damaged Components 5/31/78 All Holders of On a Bergen-Paterson erating Series 25000 Kydrau- ReactorOp(OL)or-Licenses lic Test Stand Construction Permits (CP)

Enclosure Page 1 of 2 i e

1 1 ,

i . ~

I IE Circular No. 78-10 June 14, 1978  !

Circular Subject First Date Issued To No. Of Issue 78-08 Environmental Quali- 5/31/78 All Holders of fication of Safety- Reactor Operating Related Equipment Licenses (0L) or at Nuclear Power Construction Plants Permits (CP) 78-09 Arcing of General 6/5/78 All Holders of a: Electric Company Reactor Operating Size 2 Contactors Licenses (OL) or Construction Permits (CP) 4 4

i Enclosure Page 2 of 2 4

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