ML20203C445
| ML20203C445 | |
| Person / Time | |
|---|---|
| Issue date: | 01/15/1998 |
| From: | Shirley Ann Jackson, The Chairman NRC COMMISSION (OCM) |
| To: | Hoyle J NRC OFFICE OF THE SECRETARY (SECY) |
| Shared Package | |
| ML20203C441 | List: |
| References | |
| SECY-97-288-C, NUDOCS 9802250190 | |
| Download: ML20203C445 (2) | |
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NOT ATION VOTE RESPONSE SHEET 10:
John C. Hoyle, Secretary FROM:
CHAIRMAN JACKSON
SUBJECT:
SECY 97-288 - REPORT TO CONGRESS ON ABNORMAL OCCURRENCES FOR FISCAL YEAR 1997 Approved Disapproved xx Abstain Not Participating Request Discussion COMMENTS:
l See attached coments.
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SIGNATURE '
Release Vote /XX /
January 15, 1998 DATE Withhold Vote /
/
Entered on "AS" Yes No
- n22gggg7;gis CORRESPONDENCE PDR n n,goi9o
Chairman Jackson's Comments on SECY 97 28D l disapprove the Proposed AO report as presented in SECY 97 288. I agree with Commissioner Dieus' comments regarding the need to review the items that may need to be included in Appendix C. The staff should also provide a clearly defined set of criteria for events to be included in Appendix C to prevent this in next year's report.
I also request that the staff clarify its reasoning for listing one event, AO 97-2. The s:sff should explain how the lens of the left eye received a dose of 100 rads greater than it would have received under a successful treatment when the displacement caused the source to move away from, rather than towards the left eye. The staff should provide clarification of its interpretat on regarding criteria IV(a)(1). That is, is the staff's interpretation of the criteria regarding the 100 rads delivered to the bone marrow, the lens of the eye, or to the gonads, a dose that is in addition to the dose these sites would have received in a successful treatment, or is this an absolute dose, regardless of the dose the site would have received in a successful treatment. If after review of the criteria and the facts related to the event, the staff determines that this event does not meet the AO criteria, this event should be removed from the revised AO report.
l In addition, there are several minor edits that i recommend:
Page 5, The wording of the second sentence should be changed as follows: However, according to a report from an NRC consultant, a small possibility exists;foraldn cawgdevelop in Mj90 sed area;of the thumb.
s Page 16 The wording of the third sentence of the third paragraph should be changed as follows: Because the eye applicator device was not calibrated properiy, patients received radiation doses Mxcess;of the' prescribed doses.
The last sentence should be changed as follows: The consultant hired by Dr.
Femandez identified that 202 of the patients treated were involved in the
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misadministrations.
Page 17 The first sentence of the first paragraph should be changed as follows: In addition, NRC reviewed the records of administrations done by Dr. Luis A.
V&zquez after September 1990 and identified 559 dose administrations in which 41 resulted in overdosing misadministrations.
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