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 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 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

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

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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