Press Release-I-01-006, NRC to Discuss Apparent Violation with Washington, D.C., Hospital

Press Release-I-01-006: NRC to Discuss Apparent Violation with Washington, D.C., Hospital

ML010540086
Person / Time
Issue date:	02/14/2001
From:	Office of Public Affairs Region I
To:
Category:Press Release
References
Press Release-I-01-006
Download: ML010540086 (2)

Text

NRCNEWSU.S.NUCLEARREGULATORYCOMMISSIONOFFICEOFPUBLICAFFAIRS--REGIONI475AllendaleRoadKingofPrussia,PA19406No.I-01-006February14,2001CONTACT:DianeScrenci,(610)337-5330/e-mail:dps@nrc.govNeilA.Sheehan,(610)337-5331/e-mail:nas@nrc.govNRCTODISCUSSAPPARENTVIOLATIONWITHWASHINGTON,D.C.,HOSPITALNuclearRegulatoryCommissionstaffwillmeetwithrepresentativesofaWashington,D.C.,medicalfacilityonWednesday,February21,todiscussanapparentviolationofagencyrequirements involvingtheuseofNRC-licensedradioactivematerialforcancertreatments.SibleyMemorialHospitalofficialswilltakepartinthepredecisionalenforcementconferenceat10a.m.attheNRCRegionIoffice,475AllendaleRoad,KingofPrussia,Pa.Themeetingwillbe heldinthePublicMeetingRoomandbeopentothepublic.OnSeptember28and29,2000,theNRCconductedasafetyinspectionatSibleyMemorial,locatedat5255LoughboroRoad.Theinspectionwaslimitedtoareviewoftwomisadministrations involvingapairofpatientstreatedforeyetumorswithiodine-125implantslastSeptember.(The radioactivematerialisusedtokillcancercells.)TheNRChasdeterminedthat,duetoacalculationerror,twopatientsreceiveddosestotheirtumorshigherthantheplannedamountof7,000centiGray(cGy).Specifically,theerrorresultedin onepatientbeingadministeredadoseof11,470cGyandtheotherpatientadoseof10,866cGy.AmedicalconsultantcontractedbytheNRCtorevieweacheventhasconcludedthatwhiletheremaybeanincreasedriskofcomplicationsbecauseofthehigherdoselevels,theriskissmallcompared tovisionproblemssecondarytothetreatment.Theconsultantalsofoundthatbothpatientswere checkedbytheirreferringphysiciansfollowingthemisadministrationsandnospecificadverseeffects werenoted.Basedontheinspection,theNRChasidentifiedoneapparentviolation:Afailuretohavewrittenproceduresinplacepertainingtocalculationstoensurethatradioactivesourcesorderedfromvendors foruseduringtreatmentswerethecorrectstrength.ThedecisiontoholdapredecisionalenforcementconferencedoesnotmeanthattheNRChasdeterminedaviolationhasoccurredorthatenforcementactionwillbetaken.Rather,thepurposeisto discussapparentviolations,theircausesandsafetysignificance;toprovidethelicenseewithan 2opportunitytopointoutanyerrorsthatmayhavebeenmadeintheNRCinspectionreport;andtoenablethelicenseetooutlineitsproposedcorrectiveaction.Nodecisionontheapparentviolationswillbemadeatthisconference.ThatdecisionwillbemadebyNRCofficialsatalatertime.