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 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

Addressees

All medical licensees.

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.

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 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, 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.

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 beavoided.

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

Technical Contact:

Sally Merchant, NMSS(301) 492-0637-Attachments:1. List of Recently Issued NMSSInformation Notices.2. List of Recently Issued NRCInformation Notices.

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

--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

Technical Contact:

Sally Merchant, NMSS(301) 492-0637Attachments:1. List of Recently Issued NMSSInformation Notices.2. List of Recently Issued NRCInformation Notices.E. Kraus/Tech. Ed.8/21/901311