Press Release-IV-12-041, NRC Proposes $11,200 Fine to Avera Mckennan Hospital

Press Release-IV-12-041: NRC Proposes $11,200 Fine to Avera Mckennan Hospital

ML12278A049
Person / Time
Issue date:	10/04/2012
From:	Office of Public Affairs Region IV
To:
Category:Press Release
References
Press Release-IV-12-041
Download: ML12278A049 (1)

Text

NRC NEWS U.S. NUCLEAR REGULATORY COMMISSION Office of Public Affairs Region IV 1600 E. Lamar Blvd.

Arlington, TX 76011-4511 Telephone: (817) 860-8100 Site: www.nrc.gov Blog: http://public-blog.nrc-gateway.gov No. IV-12-041

Contact:

Victor Dricks (817) 200-1128 October 04, 2012 Lara Uselding (817) 200-1519 E-Mail: OPA4.Resource@nrc.gov NRC PROPOSES $11,200 FINE TO AVERA MCKENNAN HOSPITAL The Nuclear Regulatory Commission has proposed an $11,200 fine to the Avera McKennan Hospital in Sioux Falls, S.D. for failure to implement procedures that protect patients undergoing internal radiation therapy known as brachytherapy. This violation resulted in significant and unintended radiation exposure to a patients skin on two separate occasions.

The hospital provides brachytherapy treatments to irradiate cancerous tumors inside the body.

A treatment planning computer programs the source to travel a specified distance inside a catheter to the target treatment area.

On Jan. 17, the hospitals Radiation Safety Officer notified the NRC of two incidents involving a patient who received an unintended exposure directly to the skin on two different days. This occurred because of an error in programming the computer that controls the device.

The NRC has categorized the violation as a Severity Level 2, the second most serious under the NRC enforcement program, for events that could have very serious consequences. In determining this severity level, the NRC established that the cause of the treatment error was a lack of checks and balances to ensure correct procedures are verified and followed when treating patients. When the source came into direct contact with the patients skin, it resulted in a burn.

On June 13, NRC issued an inspection report (ML12166A427) detailing the events.

Avera McKennan responded in a July 12 (ML12200A299) letter describing the immediate and long-term corrective actions. Although the licensee did take actions to prevent a reoccurrence, the NRC is issuing double the base penalty of $5,600 due to an unintended dose to a patient because of poor performance by the licensee.

Copies of the enforcement actions will be posted on the NRC web site at:

http://www.nrc.gov/reading-rm/doc-collections/enforcement/actions. The results of the NRC inspection can be found in Inspection Report 030-11252/2012-001 and ADAMS Accession Number ML12166A427.

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