ML20202F876
| ML20202F876 | |
| Person / Time | |
|---|---|
| Issue date: | 08/26/1976 |
| From: | Gilinsky V NRC COMMISSION (OCM) |
| To: | Kennedy R, Mason E, Rowden M, The Chairman NRC COMMISSION (OCM) |
| Shared Package | |
| ML20202F854 | List: |
| References | |
| NUDOCS 9902040194 | |
| Download: ML20202F876 (1) | |
Text
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NUCLEAR REGULATORY COMMISSION
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- OFFICE OF THE COMMISSIONER August 26, 1976
' MEMORANDUM FOR:
Chairman Rowden Commissioner Mason Commissioner' Kennedy Commissioner Gilinsky V' '
FROM:
SUBJECT:
Calibration Errors in Teletherapy (Riverside Hospital Incident)
I believe that the General Counsel's memorandum of August 5, 1976 (attached) should be carefully considered.
I I suggest that the GC's proposal for an organized follow-up effort be discussed at an early session, t
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9902040194 761216 PDR COMMS NRCC I
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UNITED STATES NUCLEAR REGULATORY COMMISSION WASHINGTON, D. C. 20555 g
- se August 5, 1976 l
. MEMORANDUM FOR:
Chairman Rowd'en
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Comissioner Mason Comissioner Gilinsky 4 r-l Commissioner Kennedy g
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Peter L. Strauss, General Counsel k
SUBJECT:
AUGUST 2, 1976 BRIEFING ON RIVERSIDE HOSPITAL INCIDENT In my view the' results of this meetirg repi ese'nt an appropriate first step to dsal with the most pressing immediate problem disclosed by. the incident, namely the fact that because of calibration _ errors many teletherapy patients throughout the i
l country are probably receiving doses significantly different from those prescribed.
The concluding emph' asis of'the meet-ing rightly _ focused on t;he need to be.sure rhat these machines are calibrated correctly now and henceforth.
j While the Commission obviously has a paramount concern that future damage be avoided, it also seems clear that action should be taken to identify and remedy.wher: poss4ble the human con-sequences of past errors in dosages.
Mora attention to this l
, subject appears to be needed than tM. Aug.:,t 2 briefing j
l provided.
It is my impre'ssion from the hnfing and from the documentation of this incident tha* physicians of Riverside l
l Hospital patients who received a d(,se substantially different l
from the one prescribed are being notified of this fact.
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was not clear from the briefing, however, that an organized effort is being planned to identify patients elsewhere and pro-l
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vide notification and follow.-up, where.the NBS study or futdre
-NRC evaluations indicate a likelihood that doses in error have been delivered.
I recognize that there is a major resource l
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. problem in. accomplishing this task'in view of the fact that 25,000 o'r more patients may be involved.
As was recognized at the briefing, there are also sensitive questions concern-ing possiblel liability of the hospitals'.
Nevertheless, the P"potentially explosive" nature of the affair makes it prudent as well as humane for the NRC in its position of radiation safety leadership to.make a substantial effort to assist those i
. ;who may have been injured.
i contact:-
E.L. Slaggie 492-8155 W
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2 NRC consultant Dr. Saenger, P
..s letter of May 26, 1976, indicates that many months._ study are needed, once an
' erroneously dosed patient is identified, to consider fully the needs of the patient.
Thus a-program for identifying patients affected by these errors and notifying their
' physicians is needed promptly hnd probably should commence during the NRC program for correcting existing calibration Once the latter program is effectively underway, the errors.
question of how best to proceed with identification and notifica-tion might be the subject of a future Commission briefing.
cc:
Ben Huberman-SECY (2)
Lee Gossick
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