Information Notice 1990-59, Errors in Use of Radioactive Iodine-131

Errors in Use of Radioactive Iodine-131

ML031130270
Person / Time
Site:	Beaver Valley, Millstone, Hatch, Monticello, Calvert Cliffs, Dresden, Davis Besse, Peach Bottom, Browns Ferry, Salem, Oconee, Mcguire, Nine Mile Point, Palisades, Palo Verde, Perry, Indian Point, Fermi, Kewaunee, Catawba, Harris, Wolf Creek, Saint Lucie, Point Beach, Oyster Creek, Watts Bar, Hope Creek, Grand Gulf, Cooper, Sequoyah, Byron, Pilgrim, Arkansas Nuclear, Three Mile Island, Braidwood, Susquehanna, Summer, Prairie Island, Columbia, Seabrook, Brunswick, Surry, Limerick, North Anna, Turkey Point, River Bend, Vermont Yankee, Crystal River, Haddam Neck, Ginna, Diablo Canyon, Callaway, Vogtle, Waterford, Duane Arnold, Farley, Robinson, Clinton, South Texas, San Onofre, Cook, Comanche Peak, Yankee Rowe, Maine Yankee, Quad Cities, Humboldt Bay, La Crosse, Big Rock Point, Rancho Seco, Zion, Midland, Bellefonte, Fort Calhoun, FitzPatrick, McGuire, LaSalle, Fort Saint Vrain, Shoreham, Satsop, Trojan, Atlantic Nuclear Power Plant
Issue date:	09/17/1990
From:	Cunningham R E NRC/NMSS/IMNS
To:
References
IN-90-059, NUDOCS 9009120156
Download: ML031130270 (8)

UNITED STATES NUCLEAR REGULATORY

COMMISSION

OFFICE OF NUCLEAR MATERIALS

SAFETY AND SAFEGUARDS

WASHINGTON, D.C. 20555 September

17, 1990 NRC INFORMATION

NOTICE NO. 90-59: ERRORS IN THE USE OF RADIOACTIVE

IODINE-131

Addressees

All medical licensees.

Purpose

This information

notice is intended to emphasize

to medical use licensees

the potential

radiation

dose levels resulting

from errors in the administration

of iodine-131 to humans. This issue was previously

addressed

in IE Information

Notice No. 85-61, Suppliment

1: Misadministrations

To Patients Undergoing

Thyroid Scans (attached).

Due to the significance

and frequency

of recurrence

of these errors, NRC believes this issue should be readdressed.

It is expected that licensees

will review this information

for application

to their own procedures

for the administration

of iodine-131, distribute

the notice to those responsible

for radiation

safety and quality assurance, and consider actions, if appropriate, to establish

procedures

to preclude the misadministration

of iodine-131 at their facilities.

However, suggestions

contained

in this notice do not constitute

any new U.S. Nuclear Regulatory

Commission (NRC) requirements, and no written response is required.Description

of Circumstances:

The following

cases are recent events reported to NRC that have resulted in unintended

radiation

doses to humans, as a result of the administration

of radioactive

iodine: Case 1: A patient with a history of thyroid cancer was scheduled

for her yearly whole-body

scan. Before the scan, the patient underwent

a pregnancy test, with negative results. After the pregnancy

test results were received, the technologist

began to complete a departmental

questionnaire

to obtain information

from the patient relative to the requested

procedure.

The questionnaire

addressed

the possibilities

of pregnancy

and lactation.

However, before completing

the questionnaire, the technologist

was called away and did not return to complete the form before administration

of the iodine-131.

As a result, the patient was given the intended dosage of 4.89 millicuries

of iodine-131.

Approximately

48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> later when the patient was scanned, there was considerable

iodine-131 uptake in her breasts. When questioned

by the physician, the patient indicated

that she had given birth to a female infant two weeks earlier and had been nursing this infant for approximately

the last 36 hours4.166667e-4 days <br />0.01 hours <br />5.952381e-5 weeks <br />1.3698e-5 months <br />. The total body dose to the infant was estimated

to be 17 rads, and the radiation

dose to the infant's thyroid was estimated

to be 30,000 rads. A synthetic

thyroid hormone replacement

has been prescribed

for the child, with scheduled

periodic follow-ups.

The unintended

dose to the mother's breasts was estimated

to be 8.9 rads.> 920156 Z J 4 9_0we

IN 90-59 September

17, 1990 Case 2: A patient to be scheduled

for a thyroid scan was administered

3 millicuries

of iodine-131 instead of the intended dosage of 300 microcuries

of iodine-123.

The patient's

physician

called in the request for a thyroid scan to the secretary

of the nuclear medicine department, who inadvertently

scheduled

a whole-body

scan. No written request from the physician

was required.

The dosage at this facility for a whole-body

scan is 3 millicuries

of iodine-131, whereas the dosage for a thyroid scan is 300 microcuries

of iodine-123.

The estimated

dose to the patient's

thyroid gland due to this error was 4700 rads.Case 3: A patient was scheduled

for an ectopic thyroid evaluation, with an intended dosage of 100 microcuries

of iodine-131.

In completing

the Nuclear Medicine department

referral sheet, the referring

physician

incorrectly

requested

a post-thyroidectomy

neck scan. As a result, the patient was administered

1 millicurie

of iodine-131, with an estimated

dose to the thyroid of 1300 rads.Case 4: A patient was scheduled

for an ectopic thyroid evaluation, with an Intended dosage of 50 to 100 microcuries

of iodine-131.

The technologist

consulted

the department

procedure

manual that listed prescribed

dosages for specific scans, and the dosage was incorrectly

listed as 4.5 millicuries.

As a'result, the patient was administered

4.3 millicuries.

The estimated

dose'to this patient's

thyroid gland was 4300 rads.Case 5: A patient was administered

a dosage of 15 microcuries

of iodine-131.

Almost immediately

following

the administration, the patient indicated

to the technologist

that she was approximately

4 to 5 weeks pregnant..

The technologist

failed to ask the patient if she was pregnant before the administration.

The patient had arrived at the department

with a baby in her arms, and the technologist

assumed that the patient was not pregnant.

The total body dose to the fetus was estimated

to be 2 to 4 millirem.

Since the fetal thyroid is incapable

of concentrating

iodine-131 until approximately

12 weeks of gestation, it was estimated

that there was no additional

dose to the fetal thyroid.

DISCUSSION

All licensees

are reminded of the importance

of ensuring the safe performance

of licensed activities, in accordance

with NRC regulations, requirements

of their licenses, and accepted medical practice.

The forementioned

cases illustrate:

the lack of familiarity

with appropriate

thyroid studies and dosages; the necessity

of consistently

following

quality control procedures;

and a need to understand

the significance

of radiation

doses that result -from the administration

of millicuries

versus microcuries

of radiopharmaceuticals

containing

radioiodine.

Specifically, the radiation

dose to the thyroid, resulting

from a dosage of one millicurie

rather than one microcurie

of j .

IN 90-59 September

17, 1990 iodine-131, is a one thousand-fold

increase.

In addition, the radiation

dose received from an activity of iodine-131 is approximately-100

fold greater than the dose from the same activity of iodine-123.

The following

table illustrates

the relationship

between microcurie

versus millicurie

quantities

of iodine-131, as well as the radiation

dose differential

between iodine-123 and iodine-131, for three different

age groups, with a thyroid uptake of 15 percent.TABLE: 1 year 5 years Adult A Comparison

of IsQtopes and'Radiation

Doses for Various Age Groups Assuming 15% Uptake by the Thyroid*Rads per uqi Rads per mCi I-123 1-131 I-123 1-131 old 0.07 7.40 70.3 7400 old 0.04 4.07 40.0 4070 0.007 0.78 7.0 777...* Based on information

from ICRP-Publication

No. 53 All workers should have a clear understanding

of the significance

of errors.in scale when calculating

and preparing

diagnostic

dosages versus therapeutic

dosages of radiopharmaceuticals

containing

radioiodine.

The threshold

at which a diagnostic

dosage becomes a therapeutic

dosage is low, and depends on the age of the patient and the percent uptake by the patient's

thyroid gland.Consequently, the potential

for causing a significant, undesired

radiation dose to a patient's

thyroid gland must always be kept in mind when administering

iodine radiopharmaceuticals.

Licensees

are reminded that the package inserts provided by the manufacturers

contain information

pertinent

to both proper dosages and radiation

doses, and may be valuable resources

when reviewing

imaging policies and procedures

for errors and inconsistencies.

Nuclear medicine department

procedures

should include provisions

for questioning

female patients about the possibility

of pregnancy

or lactation.

By attention

to detail, and adherence

to departmental

policy and procedures, many incidents

involving

radioactive

iodine-131 may be avoided.

r-IN 90-59 September

17, 1990 No specific written response is required by this information

notice. If you have any questions

regarding

this matter, please contact the appropriate

regional office or this office.M r Cunnnhm, ro Division of Industrial

and Medical Nuclear Safety Office of Nuclear Material Safety and Safeguards

Technical

Contact: Sally Merchant, NMSS (301) 492-0637-Attachments:

1. List of Recently Issued NMSS Information

Notices.2. List of Recently Issued NRC Information

Notices.

Attachment

1 IN 90-59 September

17, 1990 LIST OF RECENTLY ISSUED HMSS INFORMATION

NOTICES Information

Date of Notice No. Subject Issuance Issued to: 90-50 Minimization

of Methane Gas in Plant Systems and Radwaste Shipping Containers

08/08/90 All holders licenses or permits for reactors of operating construction

nuclear power 90-44 Dose-Rate

Instruments

06/29/90 90-38 Requirements

for Processing

05/29/90 Financial

Assurance

Submittals

for Decommissioning

90-35 Transportation

of Type A-Quantities

of Non-Fissile

Radioactive

Materials 90-31 Update on Waste Form and High Integrity

Container Topical Report Review Status, Identification

of Problems with Cement Solidication, and Reporting

of Waste Mishaps 90-27 Clarification

of the Recent Revisions

to the Regulatory

Requirements

for Packaging

of Uranium Hexafluoride (UF 6 ) for Transportation

90-24 Transportation

of Model SPEC 2-T Radiographic

Exposure Device 90-20 Personnel

Injuries Resulting

from Improper Operation

of Radwaste Incinerators

05/24/90 05/04/90 04/30/90 04/10/90 03/22/90 All NRC licensees All fuel facility and materials All U.S. Nuclear Regulatory

Commission (NRC) Licensees All holders of operating licenses or construction

permits for nuclear power reactors, fuel cycle licenses, and certain byproduct

materials licenses All Uranium Fuel Fabrication

and Conversion

Facilities

All NRC licensees authorized

to use, transport, or operate radiographic

exposure devices and source changers All NRC licensees who process or incinerate

radioactive

waste

--Attachment

2 -IN-90-59 !September

17, 1990. LIST OF RECENTLY ISSUED NRC INFORMATION

NOTICES Information

Date of Notice No. Subject Issuance Issued to 90-58 90-57 90-56 90-55 83-44 Supp. 1 Improper Handling of Ophthalmic

Strontium-90

Beta Radiation

Applicators

Substandard, Refurbished

Potter & Brumfield

Relays Misrepresented

As New Inadvertent

Shipment of A Radioactive

Source In A Container

Thought To Be Empty Recent Operating

Experi-ence on Loss of Reactor Coolant Inventory

While In A Shutdown Condition Potential

Damage to Redundant

Safety Equip-ment As A Result of Backflow Through the Equipment

and Floor Drain System Summary of Requalification

Program Deficiencies

Criminal Prosecution

of Wrongdoing

Committed

by Suppliers

of Nuclear Products or Services Potential

Failures of Auxiliary

Steam Piping and the Possible Effects on the Operability

of Vital Equip-ment 9/11/90 9/5/90 9/4/90 8/31/90 8/30/90 8/28/90 8/24/90 8/16/90 All NRC medical licensees.

All holders of OLs or CPs for nuclear power reactors.All U.S. Nuclear Regulatory

Com-mission (NRC)licensees.

All holders of OLs or CPs for nuclear power reactors.All holders of OLs or CPs for nuclear power reactors.All holders of GLs or CPs for nuclear power reactors.All holders of OLs or CPs for nuclear power reactors.All holders of OLs or CPs for nuclear power reactors.90-54 89-18 Supp.1 90-53 OL = Operating

License CP = Construction

Permit

IN 90-September

,1990 No specific written response is required by this information

notice. If you have any questions

regarding

this matter, please contact the appropriate

regional office or this office.~4M zlgned #1 Richard Cunningham, Director Division of Industrial

and Medical Nuclear Safety Office of Nuclear Material Safety and Safeguards

Technical

Contact: Sally Merchant, NMSS (301) 492-0637 Attachments:

1. List of Recently Issued NMSS Information

Notices.2. List of Recently Issued NRC Information

Notices.E. Kraus/Tech.

Ed.8/21/90 1311