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| | issue date = 09/17/1990 | | | issue date = 09/17/1990 |
| | title = Errors in Use of Radioactive Iodine-131 | | | title = Errors in Use of Radioactive Iodine-131 |
| | author name = Cunningham R E | | | author name = Cunningham R |
| | author affiliation = NRC/NMSS/IMNS | | | author affiliation = NRC/NMSS/IMNS |
| | addressee name = | | | addressee name = |
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| | document type = NRC Information Notice | | | document type = NRC Information Notice |
| | page count = 8 | | | page count = 8 |
| | revision = 0
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| }} | | }} |
| {{#Wiki_filter:UNITED STATESNUCLEAR REGULATORY COMMISSIONOFFICE OF NUCLEAR MATERIALS SAFETY AND SAFEGUARDSWASHINGTON, D.C. 20555September 17, 1990NRC INFORMATION NOTICE NO. 90-59:ERRORS IN THE USE OF RADIOACTIVE IODINE-131 | | {{#Wiki_filter:UNITED STATES |
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| | 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 |
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| ==Addressees== | | ==Addressees== |
| :All medical licensees. | | : |
| | All medical licensees. |
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| |
|
| ==Purpose== | | ==Purpose== |
| :This information notice is intended to emphasize to medical use licensees thepotential radiation dose levels resulting from errors in the administrationof iodine-131 to humans. This issue was previously addressed in IE InformationNotice No. 85-61, Suppliment 1: Misadministrations To Patients UndergoingThyroid Scans (attached). Due to the significance and frequency of recurrenceof these errors, NRC believes this issue should be readdressed. It is expectedthat licensees will review this information for application to their own proceduresfor the administration of iodine-131, distribute the notice to those responsiblefor radiation safety and quality assurance, and consider actions, if appropriate,to establish procedures to preclude the misadministration of iodine-131 at theirfacilities. However, suggestions contained in this notice do not constitute anynew U.S. Nuclear Regulatory Commission (NRC) requirements, and no writtenresponse is required. | | : |
| | 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== | | ==Description of Circumstances== |
| :The following cases are recent events reported to NRC that have resulted inunintended radiation doses to humans, as a result of the administration ofradioactive iodine:Case 1: A patient with a history of thyroid cancer was scheduled for heryearly whole-body scan. Before the scan, the patient underwent a pregnancytest, with negative results. After the pregnancy test results were received,the technologist began to complete a departmental questionnaire to obtaininformation from the patient relative to the requested procedure. Thequestionnaire addressed the possibilities of pregnancy and lactation. However,before completing the questionnaire, the technologist was called away and didnot return to complete the form before administration of the iodine-131. Asa result, the patient was given the intended dosage of 4.89 millicuries ofiodine-131. Approximately 48 hours later when the patient was scanned, therewas considerable iodine-131 uptake in her breasts. When questioned by thephysician, the patient indicated that she had given birth to a female infanttwo weeks earlier and had been nursing this infant for approximately the last36 hours. 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 30,000rads. A synthetic thyroid hormone replacement has been prescribed for thechild, with scheduled periodic follow-ups. The unintended dose to the mother'sbreasts was estimated to be 8.9 rads.> 920156 Z J 49_0we IN 90-59September 17, 1990 Case 2: A patient to be scheduled for a thyroid scan was administered 3millicuries of iodine-131 instead of the intended dosage of 300 microcuries ofiodine-123. The patient's physician called in the request for a thyroid scanto the secretary of the nuclear medicine department, who inadvertentlyscheduled a whole-body scan. No written request from the physician wasrequired. The dosage at this facility for a whole-body scan is 3 millicuriesof iodine-131, whereas the dosage for a thyroid scan is 300 microcuries ofiodine-123. The estimated dose to the patient's thyroid gland due to thiserror was 4700 rads.Case 3: A patient was scheduled for an ectopic thyroid evaluation, with anintended dosage of 100 microcuries of iodine-131. In completing the NuclearMedicine department referral sheet, the referring physician incorrectlyrequested a post-thyroidectomy neck scan. As a result, the patient wasadministered 1 millicurie of iodine-131, with an estimated dose to thethyroid of 1300 rads.Case 4: A patient was scheduled for an ectopic thyroid evaluation, with anIntended dosage of 50 to 100 microcuries of iodine-131. The technologistconsulted the department procedure manual that listed prescribed dosages forspecific scans, and the dosage was incorrectly listed as 4.5 millicuries. As a'result, the patient was administered 4.3 millicuries. The estimated dose'tothis 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 thetechnologist that she was approximately 4 to 5 weeks pregnant.. The technologistfailed to ask the patient if she was pregnant before the administration. Thepatient had arrived at the department with a baby in her arms, and thetechnologist assumed that the patient was not pregnant. The total body dose tothe fetus was estimated to be 2 to 4 millirem. Since the fetal thyroid isincapable of concentrating iodine-131 until approximately 12 weeks of gestation,it was estimated that there was no additional dose to the fetal thyroid. | | : |
| | 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 hours 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 the infant |
| | |
| | two weeks earlier and had been nursing this infant for approximately last |
| | |
| | 36 hours. 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 |
| | >9_0we Z 4J |
| | |
| | IN 90-59 September 17, 1990 Case 2: A patient to be scheduled for a thyroid scan was |
| | |
| | millicuries of iodine-131 instead of the intended dosage ofadministered 3 |
| | 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 |
| | |
| | required. The dosage at this facility for a whole-body scan is was |
| | |
| | 3 of iodine-131, whereas the dosage for a thyroid scan is 300 microcuriesmillicuries |
| | |
| | iodine-123. The estimated dose to the patient's thyroid gland of |
| | |
| | error was 4700 rads. due to this |
| | |
| | Case 3: A patient was scheduled for an ectopic thyroid evaluation, intended dosage of 100 microcuries of iodine-131. In completing with an |
| | |
| | Medicine department referral sheet, the referring physician the Nuclear |
| | |
| | incorrectly |
| | |
| | requested a post-thyroidectomy neck scan. As a result, the patient |
| | |
| | administered 1 millicurie of iodine-131, with an estimated dose was |
| | |
| | thyroid of 1300 rads. to the |
| | |
| | Case 4: A patient was scheduled for an ectopic thyroid evaluation, Intended dosage of 50 to 100 microcuries of iodine-131. The technologistwith an |
| | |
| | consulted the department procedure manual that listed prescribed |
| | |
| | dosages for |
| | |
| | specific scans, and the dosage was incorrectly listed as 4.5 millicuries. |
| | |
| | 'result, the patient was administered 4.3 millicuries. The estimated As a |
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| | this patient's thyroid gland was 4300 rads. dose'to |
| | |
| | Case 5: A patient was administered a dosage of 15 microcuries |
| | |
| | Almost immediately following the administration, the patient of iodine-131. |
| | |
| | technologist that she was approximately 4 to 5 weeks pregnant..indicated to the |
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| | The |
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| | failed to ask the patient if she was pregnant before the administration. technologist |
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| | patient had arrived at the department with a baby in her arms, The |
| | |
| | technologist assumed that the patient was not pregnant. The and the |
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| | the fetus was estimated to be 2 to 4 millirem. Since the fetal total body dose to |
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| | incapable of concentrating iodine-131 until approximately 12 thyroid is |
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| | weeks |
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| | it was estimated that there was no additional dose to the fetal of gestation, thyroid. |
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| ==DISCUSSION== | | ==DISCUSSION== |
| :All licensees are reminded of the importance of ensuring the safe performanceof licensed activities, in accordance with NRC regulations, requirements oftheir licenses, and accepted medical practice. The forementioned casesillustrate: the lack of familiarity with appropriate thyroid studies anddosages; 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 radiopharmaceuticalscontaining radioiodine. Specifically, the radiation dose to the thyroid,resulting from a dosage of one millicurie rather than one microcurie ofj . | | : |
| IN 90-59September 17, 1990 iodine-131, is a one thousand-fold increase. In addition, the radiation dosereceived from an activity of iodine-131 is approximately-100 fold greater thanthe dose from the same activity of iodine-123. The following table illustratesthe 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 year5 yearsAdultA Comparison of IsQtopes and'Radiation Doses forVarious Age Groups Assuming 15% Uptake by the Thyroid*Rads per uqi Rads per mCiI-123 1-131 I-123 1-131old 0.07 7.40 70.3 7400old 0.04 4.07 40.0 40700.007 0.78 7.0 777...* Based on information from ICRP-Publication No. 53All workers should have a clear understanding of the significance of errors.inscale when calculating and preparing diagnostic dosages versus therapeuticdosages of radiopharmaceuticals containing radioiodine. The threshold at whicha diagnostic dosage becomes a therapeutic dosage is low, and depends on the ageof the patient and the percent uptake by the patient's thyroid gland.Consequently, the potential for causing a significant, undesired radiationdose to a patient's thyroid gland must always be kept in mind when administeringiodine radiopharmaceuticals.Licensees are reminded that the package inserts provided by the manufacturerscontain information pertinent to both proper dosages and radiation doses,and may be valuable resources when reviewing imaging policies and proceduresfor errors and inconsistencies. Nuclear medicine department procedures shouldinclude provisions for questioning female patients about the possibility ofpregnancy or lactation. By attention to detail, and adherence to departmentalpolicy and procedures, many incidents involving radioactive iodine-131 may beavoide r-IN 90-59September 17, 1990 No specific written response is required by this information notice. If youhave any questions regarding this matter, please contact the appropriate regionaloffice or this office.M r Cunnnhm, roDivision of Industrial andMedical Nuclear SafetyOffice of Nuclear Material Safetyand Safeguards | | All licensees are reminded of the importance of ensuring the |
| | |
| | safe performance |
| | |
| | of licensed activities, in accordance with NRC regulations, requirements |
| | |
| | their licenses, and accepted medical practice. The forementioned of |
| | |
| | illustrate: the lack of familiarity with appropriate thyroid cases |
| | |
| | dosages; the necessity of consistently following quality control studies and |
| | |
| | and a need to understand the significance of radiation doses procedures; |
| | from the administration of millicuries versus microcuries of that result - |
| | containing radioiodine. Specifically, the radiation dose radiopharmaceuticals |
| | |
| | resulting from a dosage of one millicurie rather than one to the thyroid, microcurie of |
| | |
| | j . |
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| | IN 90-59 September 17, 1990 radiation dose |
| | |
| | iodine-131, is a one thousand-fold increase. In addition, the greater than |
| | |
| | received from an activity of iodine-131 is approximately-100 fold illustrates |
| | |
| | the dose from the same activity of iodine-123. The following table of iodine-131, the relationship between microcurie versus millicurie quantities and iodine-131, as well as the radiation dose differential between iodine-123 for three different age groups, with a thyroid uptake of 15 percent. |
| | |
| | TABLE: 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 |
| | 1 year old 0.07 7.40 70.3 7400 |
| | 5 years old 0.04 4.07 40.0 4070 |
| | Adult 0.007 0.78 7.0 777 |
| | . . . |
| | |
| | * Based on information from ICRP-Publication No. 53 of errors.in |
| | |
| | All workers should have a clear understanding of the significance therapeutic |
| | |
| | scale when calculating and preparing diagnostic dosages versusthreshold at which |
| | |
| | dosages of radiopharmaceuticals containing radioiodine. The on the age |
| | |
| | a diagnostic dosage becomes a therapeutic dosage is low, and depends |
| | |
| | thyroid gland. |
| | |
| | of the patient and the percent uptake by the patient's radiation |
| | |
| | Consequently, the potential for causing a significant, undesired when administering |
| | |
| | dose to a patient's thyroid gland must always be kept in mind |
| | |
| | iodine radiopharmaceuticals. |
| | |
| | manufacturers |
| | |
| | Licensees are reminded that the package inserts provided by the doses, contain information pertinent to both proper dosages and radiation |
| | |
| | when reviewing imaging policies and procedures |
| | |
| | and may be valuable resources should |
| | |
| | for errors and inconsistencies. Nuclear medicine department procedures of |
| | |
| | include provisions for questioning female patients about the possibility |
| | |
| | pregnancy or lactation. By attention to detail, and adherence to departmental may be |
| | |
| | policy and procedures, many incidents involving radioactive iodine-131 avoided. |
| | |
| | r- IN 90-59 September 17, 1990 No specific written response is required by this information |
| | |
| | have any questions regarding this matter, please contact notice. If you |
| | |
| | office or this office. the appropriate regional |
| | |
| | M rCunnnhm, ro |
| | |
| | Division of Industrial and |
| | |
| | Medical Nuclear Safety |
| | |
| | Office of Nuclear Material Safety |
| | |
| | and Safeguards |
|
| |
|
| ===Technical Contact:=== | | ===Technical Contact:=== |
| Sally Merchant, NMSS(301) 492-0637-
| |
|
| |
|
| ===Attachments:=== | | ===Sally Merchant, NMSS=== |
| 1. List of Recently Issued NMSSInformation Notices.2. List of Recently Issued NRCInformation Notice Attachment 1IN 90-59September 17, 1990 LIST OF RECENTLY ISSUEDHMSS INFORMATION NOTICESInformation Date ofNotice No. Subject Issuance Issued to:90-50Minimization of Methane Gasin Plant Systems and RadwasteShipping Containers08/08/90All holderslicenses orpermits forreactorsof operatingconstructionnuclear power90-44Dose-Rate Instruments06/29/9090-38 Requirements for Processing 05/29/90Financial Assurance Submittalsfor Decommissioning90-35 Transportation of Type A-Quantities of Non-FissileRadioactive Materials90-31 Update on Waste Form andHigh Integrity ContainerTopical Report Review Status,Identification of Problemswith Cement Solidication, andReporting of Waste Mishaps90-27 Clarification of theRecent Revisions to theRegulatory Requirementsfor Packaging of UraniumHexafluoride (UF6 ) forTransportation90-24 Transportation of ModelSPEC 2-T RadiographicExposure Device90-20 Personnel InjuriesResulting from ImproperOperation of RadwasteIncinerators05/24/9005/04/9004/30/9004/10/9003/22/90All NRC licenseesAll fuel facilityand materialsAll U.S. NuclearRegulatory Commission(NRC) LicenseesAll holders of operatinglicenses or constructionpermits for nuclear powerreactors, fuel cyclelicenses, and certainbyproduct materialslicensesAll Uranium FuelFabrication and ConversionFacilitiesAll NRC licenseesauthorized to use,transport, or operateradiographic exposuredevices and sourcechangersAll NRC licenseeswho process or incinerateradioactive waste | | (301) 492-0637- Attachments: |
| --Attachment 2 -IN-90-59 !September 17, 1990. LIST OF RECENTLY ISSUEDNRC INFORMATION NOTICESInformation Date ofNotice No. Subject Issuance Issued to90-5890-5790-5690-5583-44Supp. 1Improper Handling ofOphthalmic Strontium-90Beta Radiation ApplicatorsSubstandard, RefurbishedPotter & Brumfield RelaysMisrepresented As NewInadvertent Shipment of ARadioactive Source In AContainer Thought To BeEmptyRecent Operating Experi-ence on Loss of ReactorCoolant Inventory WhileIn A Shutdown ConditionPotential Damage toRedundant Safety Equip-ment As A Result ofBackflow Through theEquipment and Floor DrainSystemSummary of RequalificationProgram DeficienciesCriminal Prosecution ofWrongdoing Committed bySuppliers of NuclearProducts or ServicesPotential Failures ofAuxiliary Steam Piping andthe Possible Effects on theOperability of Vital Equip-ment9/11/909/5/909/4/908/31/908/30/908/28/908/24/908/16/90All NRC medicallicensees.All holders of OLsor CPs for nuclearpower reactors.All U.S. NuclearRegulatory Com-mission (NRC)licensees.All holders of OLsor CPs for nuclearpower reactors.All holders of OLsor CPs for nuclearpower reactors.All holders of GLsor CPs for nuclearpower reactors.All holders of OLsor CPs for nuclearpower reactors.All holders of OLsor CPs for nuclearpower reactors.90-5489-18Supp.190-53OL = Operating LicenseCP = Construction Permit IN 90-September ,1990 No specific written response is required by this information notice. If youhave any questions regarding this matter, please contact the appropriateregional office or this office.~4M zlgned #1Richard Cunningham, DirectorDivision of Industrial andMedical Nuclear SafetyOffice of Nuclear Material Safetyand Safeguards | | 1. List of Recently Issued NMSS |
| | |
| | Information Notices. |
| | |
| | 2. List of Recently Issued NRC |
| | |
| | Information Notices. |
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| | Attachment 1 IN 90-59 September 17, 1990 LIST OF RECENTLY ISSUED |
| | |
| | HMSS INFORMATION NOTICES |
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| | ===Information Date of=== |
| | Notice No. Subject Issuance Issued to: |
| | 90-50 Minimization of Methane Gas 08/08/90 All holders of operating |
| | |
| | in Plant Systems and Radwaste licenses or construction |
| | |
| | Shipping Containers permits for nuclear power |
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| | reactors |
| | |
| | 90-44 Dose-Rate Instruments 06/29/90 All NRC licensees |
| | |
| | 90-38 Requirements for Processing 05/29/90 All fuel facility |
| | |
| | Financial Assurance Submittals and materials |
| | |
| | for Decommissioning |
| | |
| | 90-35 Transportation of Type A 05/24/90 All U.S. Nuclear |
| | |
| | - Quantities of Non-Fissile Regulatory Commission |
| | |
| | Radioactive Materials (NRC) Licensees |
| | |
| | 90-31 Update on Waste Form and 05/04/90 All holders of operating |
| | |
| | High Integrity Container licenses or construction |
| | |
| | Topical Report Review Status, permits for nuclear power |
| | |
| | Identification of Problems reactors, fuel cycle |
| | |
| | with Cement Solidication, and licenses, and certain |
| | |
| | Reporting of Waste Mishaps byproduct materials |
| | |
| | licenses |
| | |
| | 90-27 Clarification of the 04/30/90 All Uranium Fuel |
| | |
| | Recent Revisions to the Fabrication and Conversion |
| | |
| | Regulatory Requirements Facilities |
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| | for Packaging of Uranium |
| | |
| | Hexafluoride (UF6 ) for |
| | |
| | Transportation |
| | |
| | 90-24 Transportation of Model 04/10/90 All NRC licensees |
| | |
| | SPEC 2-T Radiographic authorized to use, Exposure Device transport, or operate |
| | |
| | radiographic exposure |
| | |
| | devices and source |
| | |
| | changers |
| | |
| | 90-20 Personnel Injuries 03/22/90 All NRC licensees |
| | |
| | Resulting from Improper who process or incinerate |
| | |
| | Operation of Radwaste radioactive waste |
| | |
| | Incinerators |
| | |
| | - - 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 Improper Handling of 9/11/90 All NRC medical |
| | |
| | Ophthalmic Strontium-90 licensees. |
| | |
| | Beta Radiation Applicators |
| | |
| | 90-57 Substandard, Refurbished 9/5/90 All holders of OLs |
| | |
| | Potter & Brumfield Relays or CPs for nuclear |
| | |
| | Misrepresented As New power reactors. |
| | |
| | 90-56 Inadvertent Shipment of A 9/4/90 All U.S. Nuclear |
| | |
| | Radioactive Source In A Regulatory Com- Container Thought To Be mission (NRC) |
| | Empty licensees. |
| | |
| | 90-55 Recent Operating Experi- 8/31/90 All holders of OLs |
| | |
| | ence on Loss of Reactor or CPs for nuclear |
| | |
| | Coolant Inventory While power reactors. |
| | |
| | In A Shutdown Condition |
| | |
| | 83-44 Potential Damage to 8/30/90 All holders of OLs |
| | |
| | Supp. 1 Redundant Safety Equip- or CPs for nuclear |
| | |
| | ment As A Result of power reactors. |
| | |
| | Backflow Through the |
| | |
| | Equipment and Floor Drain |
| | |
| | System |
| | |
| | 90-54 Summary of Requalification 8/28/90 All holders of GLs |
| | |
| | Program Deficiencies or CPs for nuclear |
| | |
| | power reactors. |
| | |
| | 89-18 Criminal Prosecution of 8/24/90 All holders of OLs |
| | |
| | Supp. 1 Wrongdoing Committed by or CPs for nuclear |
| | |
| | Suppliers of Nuclear power reactors. |
| | |
| | Products or Services |
| | |
| | 90-53 Potential Failures of 8/16/90 All holders of OLs |
| | |
| | Auxiliary Steam Piping and or CPs for nuclear |
| | |
| | the Possible Effects on the power reactors. |
| | |
| | Operability of Vital Equip- ment |
| | |
| | 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:=== | | ===Technical Contact:=== |
| Sally Merchant, NMSS(301) 492-0637
| |
|
| |
|
| ===Attachments:=== | | ===Sally Merchant, NMSS=== |
| 1. List of Recently Issued NMSSInformation Notices.2. List of Recently Issued NRCInformation Notices.E. Kraus/Tech. Ed.8/21/901311}} | | (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}} |
|
| |
|
| {{Information notice-Nav}} | | {{Information notice-Nav}} |
Errors in Use of Radioactive Iodine-131ML031130270 |
Person / Time |
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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 ![Entergy icon.png](/w/images/7/79/Entergy_icon.png) |
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Issue date: |
09/17/1990 |
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From: |
Cunningham R NRC/NMSS/IMNS |
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To: |
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References |
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IN-90-059, NUDOCS 9009120156 |
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Category:NRC Information Notice
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Mclaughlin on NRC, Regarding NRC Information Notice 2006-13: Groundwater Contamination 2020-09-03 The following query condition could not be considered due to this wiki's restrictions on query size or depth: <code> [[:Beaver Valley]] OR [[:Millstone]] OR [[:Hatch]] OR [[:Monticello]] OR [[:Calvert Cliffs]] OR [[:Dresden]] OR [[:Davis Besse]] OR [[:Peach Bottom]] OR [[:Browns Ferry]] OR [[:Salem]] OR [[:Oconee]] OR [[:Mcguire]] OR [[:Nine Mile Point]] OR [[:Palisades]] OR [[:Palo Verde]] OR [[:Perry]] OR [[:Indian Point]] OR [[:Fermi]] OR [[:Kewaunee]] OR [[:Catawba]] OR [[:Harris]] OR [[:Wolf Creek]] OR [[:Saint Lucie]] OR [[:Point Beach]] OR [[:Oyster Creek]] OR [[:Watts Bar]] OR [[:Hope Creek]] OR [[:Grand Gulf]] OR [[:Cooper]] OR [[:Sequoyah]] OR [[:Byron]] OR [[:Pilgrim]] OR [[:Arkansas Nuclear]] OR [[:Three Mile Island]] OR [[:Braidwood]] OR [[:Susquehanna]] OR [[:Summer]] OR [[:Prairie Island]] OR [[:Columbia]] OR [[:Seabrook]] OR [[:Brunswick]] OR [[:Surry]] OR [[:Limerick]] OR [[:North Anna]] OR [[:Turkey Point]] OR [[:River Bend]] OR [[:Vermont Yankee]] OR [[:Crystal River]] OR [[:Haddam Neck]] OR [[:Ginna]] OR [[:Diablo Canyon]] OR [[:Callaway]] OR [[:Vogtle]] OR [[:Waterford]] OR [[:Duane Arnold]] OR [[:Farley]] OR [[:Robinson]] OR [[:Clinton]] OR [[:South Texas]] OR [[:San Onofre]] OR [[:Cook]] OR [[:Comanche Peak]] OR [[:Yankee Rowe]] OR [[:Maine Yankee]] OR [[:Quad Cities]] OR [[:Humboldt Bay]] OR [[:La Crosse]] OR [[:Big Rock Point]] OR [[:Rancho Seco]] OR [[:Zion]] OR [[:Midland]] OR [[:Bellefonte]] OR [[:Fort Calhoun]] OR [[:FitzPatrick]] OR [[:McGuire]] OR [[:LaSalle]] OR [[:Fort Saint Vrain]] OR [[:Shoreham]] OR [[:Satsop]] OR [[:Trojan]] OR [[:Atlantic Nuclear Power Plant]] </code>.
[Table view]The following query condition could not be considered due to this wiki's restrictions on query size or depth: <code> [[:Beaver Valley]] OR [[:Millstone]] OR [[:Hatch]] OR [[:Monticello]] OR [[:Calvert Cliffs]] OR [[:Dresden]] OR [[:Davis Besse]] OR [[:Peach Bottom]] OR [[:Browns Ferry]] OR [[:Salem]] OR [[:Oconee]] OR [[:Mcguire]] OR [[:Nine Mile Point]] OR [[:Palisades]] OR [[:Palo Verde]] OR [[:Perry]] OR [[:Indian Point]] OR [[:Fermi]] OR [[:Kewaunee]] OR [[:Catawba]] OR [[:Harris]] OR [[:Wolf Creek]] OR [[:Saint Lucie]] OR [[:Point Beach]] OR [[:Oyster Creek]] OR [[:Watts Bar]] OR [[:Hope Creek]] OR [[:Grand Gulf]] OR [[:Cooper]] OR [[:Sequoyah]] OR [[:Byron]] OR [[:Pilgrim]] OR [[:Arkansas Nuclear]] OR [[:Three Mile Island]] OR [[:Braidwood]] OR [[:Susquehanna]] OR [[:Summer]] OR [[:Prairie Island]] OR [[:Columbia]] OR [[:Seabrook]] OR [[:Brunswick]] OR [[:Surry]] OR [[:Limerick]] OR [[:North Anna]] OR [[:Turkey Point]] OR [[:River Bend]] OR [[:Vermont Yankee]] OR [[:Crystal River]] OR [[:Haddam Neck]] OR [[:Ginna]] OR [[:Diablo Canyon]] OR [[:Callaway]] OR [[:Vogtle]] OR [[:Waterford]] OR [[:Duane Arnold]] OR [[:Farley]] OR [[:Robinson]] OR [[:Clinton]] OR [[:South Texas]] OR [[:San Onofre]] OR [[:Cook]] OR [[:Comanche Peak]] OR [[:Yankee Rowe]] OR [[:Maine Yankee]] OR [[:Quad Cities]] OR [[:Humboldt Bay]] OR [[:La Crosse]] OR [[:Big Rock Point]] OR [[:Rancho Seco]] OR [[:Zion]] OR [[:Midland]] OR [[:Bellefonte]] OR [[:Fort Calhoun]] OR [[:FitzPatrick]] OR [[:McGuire]] OR [[:LaSalle]] OR [[:Fort Saint Vrain]] OR [[:Shoreham]] OR [[:Satsop]] OR [[:Trojan]] OR [[:Atlantic Nuclear Power Plant]] </code>. |
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 the infant
two weeks earlier and had been nursing this infant for approximately 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
>9_0we Z 4J
IN 90-59 September 17, 1990 Case 2: A patient to be scheduled for a thyroid scan was
millicuries of iodine-131 instead of the intended dosage ofadministered 3
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
required. The dosage at this facility for a whole-body scan is was
3 of iodine-131, whereas the dosage for a thyroid scan is 300 microcuriesmillicuries
iodine-123. The estimated dose to the patient's thyroid gland of
error was 4700 rads. due to this
Case 3: A patient was scheduled for an ectopic thyroid evaluation, intended dosage of 100 microcuries of iodine-131. In completing with an
Medicine department referral sheet, the referring physician the Nuclear
incorrectly
requested a post-thyroidectomy neck scan. As a result, the patient
administered 1 millicurie of iodine-131, with an estimated dose was
thyroid of 1300 rads. to the
Case 4: A patient was scheduled for an ectopic thyroid evaluation, Intended dosage of 50 to 100 microcuries of iodine-131. The technologistwith an
consulted the department procedure manual that listed prescribed
dosages for
specific scans, and the dosage was incorrectly listed as 4.5 millicuries.
'result, the patient was administered 4.3 millicuries. The estimated As a
this patient's thyroid gland was 4300 rads. dose'to
Case 5: A patient was administered a dosage of 15 microcuries
Almost immediately following the administration, the patient of iodine-131.
technologist that she was approximately 4 to 5 weeks pregnant..indicated to the
The
failed to ask the patient if she was pregnant before the administration. technologist
patient had arrived at the department with a baby in her arms, The
technologist assumed that the patient was not pregnant. The and the
the fetus was estimated to be 2 to 4 millirem. Since the fetal total body dose to
incapable of concentrating iodine-131 until approximately 12 thyroid is
weeks
it was estimated that there was no additional dose to the fetal of gestation, thyroid.
DISCUSSION
All licensees are reminded of the importance of ensuring the
safe performance
of licensed activities, in accordance with NRC regulations, requirements
their licenses, and accepted medical practice. The forementioned of
illustrate: the lack of familiarity with appropriate thyroid cases
dosages; the necessity of consistently following quality control studies and
and a need to understand the significance of radiation doses procedures;
from the administration of millicuries versus microcuries of that result -
containing radioiodine. Specifically, the radiation dose radiopharmaceuticals
resulting from a dosage of one millicurie rather than one to the thyroid, microcurie of
j .
IN 90-59 September 17, 1990 radiation dose
iodine-131, is a one thousand-fold increase. In addition, the greater than
received from an activity of iodine-131 is approximately-100 fold illustrates
the dose from the same activity of iodine-123. The following table of iodine-131, the relationship between microcurie versus millicurie quantities and iodine-131, as well as the radiation dose differential between iodine-123 for three different age groups, with a thyroid uptake of 15 percent.
TABLE: 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
1 year old 0.07 7.40 70.3 7400
5 years old 0.04 4.07 40.0 4070
Adult 0.007 0.78 7.0 777
. . .
- Based on information from ICRP-Publication No. 53 of errors.in
All workers should have a clear understanding of the significance therapeutic
scale when calculating and preparing diagnostic dosages versusthreshold at which
dosages of radiopharmaceuticals containing radioiodine. The on the age
a diagnostic dosage becomes a therapeutic dosage is low, and depends
thyroid gland.
of the patient and the percent uptake by the patient's radiation
Consequently, the potential for causing a significant, undesired when administering
dose to a patient's thyroid gland must always be kept in mind
iodine radiopharmaceuticals.
manufacturers
Licensees are reminded that the package inserts provided by the doses, contain information pertinent to both proper dosages and radiation
when reviewing imaging policies and procedures
and may be valuable resources should
for errors and inconsistencies. Nuclear medicine department procedures of
include provisions for questioning female patients about the possibility
pregnancy or lactation. By attention to detail, and adherence to departmental may be
policy and procedures, many incidents involving radioactive iodine-131 avoided.
r- IN 90-59 September 17, 1990 No specific written response is required by this information
have any questions regarding this matter, please contact notice. If you
office or this office. the appropriate regional
M rCunnnhm, 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 08/08/90 All holders of operating
in Plant Systems and Radwaste licenses or construction
Shipping Containers permits for nuclear power
reactors
90-44 Dose-Rate Instruments 06/29/90 All NRC licensees
90-38 Requirements for Processing 05/29/90 All fuel facility
Financial Assurance Submittals and materials
for Decommissioning
90-35 Transportation of Type A 05/24/90 All U.S. Nuclear
- Quantities of Non-Fissile Regulatory Commission
Radioactive Materials (NRC) Licensees
90-31 Update on Waste Form and 05/04/90 All holders of operating
High Integrity Container licenses or construction
Topical Report Review Status, permits for nuclear power
Identification of Problems reactors, fuel cycle
with Cement Solidication, and licenses, and certain
Reporting of Waste Mishaps byproduct materials
licenses
90-27 Clarification of the 04/30/90 All Uranium Fuel
Recent Revisions to the Fabrication and Conversion
Regulatory Requirements Facilities
for Packaging of Uranium
Hexafluoride (UF6 ) for
Transportation
90-24 Transportation of Model 04/10/90 All NRC licensees
SPEC 2-T Radiographic authorized to use, Exposure Device transport, or operate
radiographic exposure
devices and source
changers
90-20 Personnel Injuries 03/22/90 All NRC licensees
Resulting from Improper who process or incinerate
Operation of Radwaste radioactive waste
Incinerators
- - 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 Improper Handling of 9/11/90 All NRC medical
Ophthalmic Strontium-90 licensees.
Beta Radiation Applicators
90-57 Substandard, Refurbished 9/5/90 All holders of OLs
Potter & Brumfield Relays or CPs for nuclear
Misrepresented As New power reactors.
90-56 Inadvertent Shipment of A 9/4/90 All U.S. Nuclear
Radioactive Source In A Regulatory Com- Container Thought To Be mission (NRC)
Empty licensees.
90-55 Recent Operating Experi- 8/31/90 All holders of OLs
ence on Loss of Reactor or CPs for nuclear
Coolant Inventory While power reactors.
In A Shutdown Condition
83-44 Potential Damage to 8/30/90 All holders of OLs
Supp. 1 Redundant Safety Equip- or CPs for nuclear
ment As A Result of power reactors.
Backflow Through the
Equipment and Floor Drain
System
90-54 Summary of Requalification 8/28/90 All holders of GLs
Program Deficiencies or CPs for nuclear
power reactors.
89-18 Criminal Prosecution of 8/24/90 All holders of OLs
Supp. 1 Wrongdoing Committed by or CPs for nuclear
Suppliers of Nuclear power reactors.
Products or Services
90-53 Potential Failures of 8/16/90 All holders of OLs
Auxiliary Steam Piping and or CPs for nuclear
the Possible Effects on the power reactors.
Operability of Vital Equip- ment
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
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list | - Information Notice 1990-01, Importance of Proper Response to Self-Identified Violations by Licensees (12 January 1990, Topic: Uranium Hexafluoride)
- Information Notice 1990-02, Potential Degradation of Secondary Containment (22 January 1990)
- Information Notice 1990-03, Malfunction of Borg-Warner Bolted Bonnet Check Valves Caused by Failure of the Swing Arm (23 January 1990, Topic: Liquid penetrant)
- Information Notice 1990-04, Cracking of the Upper Shell-to-Transition Cone Girth Welds in Steam Generators, (26 January 1990, Topic: Nondestructive Examination)
- Information Notice 1990-05, Inter-System Discharge of Reactor Coolant (29 January 1990)
- Information Notice 1990-06, Potential for Loss of Shutdown Cooling While at Low Reactor Coolant Levels (29 January 1990)
- Information Notice 1990-07, New Information Regarding Insulation Material Performance and Debris Blockage of PWR Containment Sumps (30 January 1990)
- Information Notice 1990-08, KR-85 Hazards from Decayed Fuel (1 February 1990)
- Information Notice 1990-08, KR-85 Hazards From Decayed Fuel (1 February 1990)
- Information Notice 1990-09, Extended Interim Storage of Low-Level Radioactive Waste by Fuel Cycle and Materials Licensees (5 February 1990, Topic: Decommissioning Funding Plan)
- Information Notice 1990-10, Primary Water Stress Corrosion Cracking (PWSCC) of Inconel 600 (23 February 1990, Topic: Boric Acid, Hydrostatic, Liquid penetrant)
- Information Notice 1990-10, Primary Water Stress Corrosion Cracking of Inconel 600 (23 February 1990, Topic: Boric Acid, Hydrostatic, Nondestructive Examination, Liquid penetrant)
- Information Notice 1990-11, Maintenance Deficiency Associated with Solenoid-Operated Valves (28 February 1990)
- Information Notice 1990-12, Monitoring or Interruption of Plant Communications (28 February 1990)
- Information Notice 1990-13, Importance of Review and Analysis of Safeguards Event Logs (5 March 1990)
- Information Notice 1990-14, Accidental Disposal of Radioactive Materials (6 March 1990, Topic: Brachytherapy)
- Information Notice 1990-15, Reciprocity Notification of Agreement State Radiation Control Directors Before Beginning Work in Agreement States (17 March 1990, Topic: Uranium Hexafluoride)
- Information Notice 1990-16, Compliance with New Decommissioning Rule (7 March 1990)
- Information Notice 1990-17, Weight and Center of Gravity Discrepancies for Copes-Vulcan Valves (8 March 1990, Topic: Earthquake)
- Information Notice 1990-18, Potential Problems with Crosby Safety Relief Valves Used on Diesel Generator Air Start Receiver Tanks (9 March 1990)
- Information Notice 1990-18, Potential Problems With Crosby Safety Relief Valves Used on Diesel Generator Air Start Receiver Tanks (9 March 1990)
- Information Notice 1990-19, Potential Loss of Effective Volume for Containment Recirculation Spray at PWR Facilities (14 March 1990)
- Information Notice 1990-20, Personnel Injuries Resulting from Improper Operation of Radwaste Incinerators (22 March 1990)
- Information Notice 1990-21, Potential Failure of Motor-Operated Butterfly Valves to Operate Because Valve Seat Friction was Underestimated (22 March 1990)
- Information Notice 1990-21, Potential Failure of Motor-Operated Butterfly Valves to Operate Because Valve Seat Friction Was Underestimated (22 March 1990)
- Information Notice 1990-22, Unanticipated Equipment Actuations Following Restoration of Power to Rosemount Transmitter Trip Units (23 March 1990, Topic: Reactor Vessel Water Level)
- Information Notice 1990-23, Improper Installation of Patel Conduit Seals (4 April 1990)
- Information Notice 1990-24, Transportation of Model Spec 2-T Radiographic Exposure Device (10 April 1990)
- Information Notice 1990-24, Transportation of Model SPEC 2-T Radiographic Exposure Device (10 April 1990)
- Information Notice 1990-25, Loss of Vital AC Power With Subsequent Reactor Coolant System Heat-Up (16 April 1990)
- Information Notice 1990-25, Loss of Vital AC Power with Subsequent Reactor Coolant System Heat-Up (16 April 1990)
- Information Notice 1990-26, Inadequate Flow of Essential Service Water to Room Coolers and Heat Exchangers for Engineered Safety-Feature Systems (24 April 1990)
- Information Notice 1990-27, Clarification of the Recent Revisions to the Regulatory Requirements for Packaging of Uranium Hexafluoride (UF6) for Transportation (30 April 1990)
- Information Notice 1990-28, Potential Error In High Steamline Flow Setpoint (30 April 1990)
- Information Notice 1990-28, Potential Error in High Steamline Flow Setpoint (30 April 1990)
- Information Notice 1990-29, Cracking of Cladding and Its Heat-Affected Zone in the Base Metal of a Reactor Vessel Head (30 April 1990, Topic: Nondestructive Examination, Liquid penetrant)
- Information Notice 1990-30, Ultrasonic Inspection Techniques for Dissimilar Metal Welds (1 May 1999, Topic: Dissimilar Metal Weld)
- Information Notice 1990-31, Update on Waste Form and High Integrity Container Topical Report Review Status, Identification of Problems with Cement Solidification, and Reporting of Waste Mishaps (4 May 1990, Topic: Process Control Program)
- Information Notice 1990-31, Update on Waste form and High Integrity Container Topical Report Review Status, Identification of Problems with Cement Solidification, and Reporting of Waste Mishaps (4 May 1990, Topic: Process Control Program)
- Information Notice 1990-32, Surface Crack and Subsurface Indications in the Weld of a Reactor Vessel Head (3 May 1990)
- Information Notice 1990-33, Sources of Unexpected Occupational Radiation Exposures at Spent Fuel Storage Pools (9 May 1990)
- Information Notice 1990-34, Response to False Siren Activations (10 May 1990)
- Information Notice 1990-35, Transportation of Type a Quantities of Non-Fissile Radioactive Materials (24 May 1990)
- Information Notice 1990-37, Sheared Pinion Gear-To-Shaft Keys in Limitorque Motor Actuators (24 May 1990)
- Information Notice 1990-38, License and Fee Requirements for Processing Financial Assurance Submittals for Decommissioning (6 November 1990, Topic: Authorized possession limits)
- Information Notice 1990-39, Recent Problems with Service Water Systems (1 June 1990)
- Information Notice 1990-40, Results of NRC-Sponsored Testing of Motor-Operated Valves (5 June 1990, Topic: Weak link)
- Information Notice 1990-41, Potential Failure of General Electric Magne-Blast Circuit Breakers and Ak Circuit Breakers (12 June 1990)
- Information Notice 1990-42, Failure of Electrical Power Equipment Due to Solar Magnetic Disturbances (19 June 1990)
- Information Notice 1990-43, Mechanical Interference with Thermal Trip Function in GE Molded-Case Circuit Breakers (29 June 1990)
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