ML20127L520
| ML20127L520 | |
| Person / Time | |
|---|---|
| Issue date: | 12/31/1990 |
| From: | Fitzgerald E NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| Shared Package | |
| ML20127B580 | List: |
| References | |
| FOIA-92-67 NUDOCS 9211240354 | |
| Download: ML20127L520 (17) | |
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!a axcwena the frahm cf information Act wd.io.s_hnD Mpf a f 0!A _A7 -17 p#'#[ December 31, 1990 MEMORANDUM FOR: File FROM: Edward A. Fitzgerald, Investigator /
Office of Investigations Field Offic , Region 1 '
SUBJECT:
REVIEW OF RADIATICF SAFETY COMMITTEE MEETING MINUTES NOVEMBER 1989; JANUARY 1990; JUNE 1990; SEPTEMBER 1990; AND NOVEMBER.
1990,VETERANSADMINISTRATIONMEDICALCENTER(VAMC)(CASE q NO.1-90-018)
On December 12, 1990, Dr. Lawrence Flesh, Ch i , of Staff, VAMC, was requested '.
by 01 Investigator Edward A. Fitzgerald to furnish copies-of minutes of-Radiation Safety Committee meetings _ for 1989 and 1990.
The following 1989/1990 meeting minutes were reviewed for indications of .
sealed sources inventory problems discussed by the Safety Comittee. l
- 1. November 30, 1989 - Dr. Andrew Kang, temporary Radiation Safety Officer-(R50) reports to the Comittee that VAMC performed only one sealed source inventory in a six month period of 1989 and was cited by a NRC inspection-in October 1989. Kang said that a quarterly inventory-is a requirement.
- 2. January 25, 1990 - No problems-relating to se*d sources inventories discussed.
- 3. June 14, 1990 - No problems relating to sealed source inventory discussed.
- 4. September 27, 1990 - One radiation safety incident, loss of radioactive material (package'of 1 mci of tritium). A report filed with NRC. - No other problems reported relating to sealed sources.
NOTE: At this meeting Dr. James ZHANG was introduced as the new Radiation Safety Officer.
- 5. November 29, 1990 - It was noted that certified health physicist was hired as a cons 5Ttant in radiation safety. A-lengthy discussion ,
concerning the NRC inspcetion of November 20,and 21 was held. A new inventory va:. ordered by NRC to be submitted by Dece-ber 7,1990. The VAMC was also directed to appear in the NRC Region i c.ffices to provide a plan to reenver from an estimate of twenty violations.
The review of the meeting minutes indicates that the RSO did not present' to !
the Safety Committee any problems with accountability of sealed sources for the first three quarters of 1990 until after the NRC inspection of November 1990. It is noted that at the November 30, 1989, meeting Karl reported that the.NRC cited the VAMC for performing enly one sealed source inventory during_
g a six month period when a quarterly inventory is the requirement. EXHIBIT ' /6s 9211240354 920511 7" <..
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RADI ATICt1 SAFETY /RADIOISOIDPE CCt4MI'ITEC MEETIt1G taovember 30, 1989 MEMBERS PRESDTT:
Lawrence 11. Flesh, M.D. Chief of Staff Pocheng Cheng, Ph.D. Radiation 'Dierapy Service Charles A. Hall, M.D. Medical Service Paula llemings, R.tl. t1ursing Service S. A. Kang, M.D) Acting Radiation Safety Officer / Chairman Peter Maloy, M.D. Surgical Service Min-Pu Tsan, M.D. Ph.D. ACOS, Research Service --
An-Ya Wu, M.D. Laboratory Service MEMBEPS ABSDJT:
Sail Capel, M.D. Acting Chief, Radiology Service OLD BUSItJESS:
Acceptance of Minutes The minutes from the September 28, 1989, meeting were accepted unanimously.
30RTIONSOUTSIDESCOPEOFREQUES17 Dr. Kang notified the comittee that there was an unexpected t1RC inspection in October immediately after the previous Radiation Safety Officer resigned.
The following were the only suggestiuns made by the inspector because of recent changes in regulations:
- 1. Quality Control Reporting - Tc-99m Generator - Date and Time should be recorded when Molly Assay is performed.
- 2. Sealed Source Inventory - Requi 3 to be performed cuarterly, hewever, it was noted that during one six month period, it was performed only ence.
EXHIBIT C 5 /. , 7, , PAGE S OF /3 P.\GyC)
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S. A. KANG, M.D.
Chairrr.an, Radiation Safety / Radioisotope Ccanittee teting Radiation Safety Officer s
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1 MIt1UTES RADIATIO!4 SAFETY / RADIOISOTOPE COMMITTEE January 25, 1990 MEMBERS PRESEtiT:
Lawrence H. Flesh, M.D. Chief of Staff .
Charles A. Hall M.D. Medical Service S.A. Kang, M . D . ', Acting Radiation Safety Officer / Chairman Angel Termin, M.D. Radiology Service MEMBERS ABSENT:
Pocheng Cheng, Ph.D. Radiation Therapy Service Paula Hemmings, R . fl . Nurs.nq Service Peter Maloy, M.D. Surgical Service Min-Fu Tsan, M.D., Ph.D. ACOS, Research Service An-Ya Wu, M.D. Laboratory Service OLD BUSIt1ESS:
Acceptance of Minutes:
Minutes from the tiovember 30, 1989, meeting were accepted.
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PORTIONS OUTSIDE SCOPE OF REQUEST b(\
l Current Status of Recruitment for RSO Dr. Kang announced that Dr. Terry Teslow is scheduled to be interviewed on 1/26/90 for the RSO position. His credentials were reviewed with the committee and Dr. Kang offered to introduce Dr. Teslow to members who are interested in meeting him during his visit.
EXHIBIT b gg ,f,4 PAGE OF $ PAGE(S)
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0 5 PORTIONS OUTSIDE SCOPE OF REQUEST S. A.
l K A t1 G , M.D tw Chairman, Radia ion Safety / Radioisotope Committee Acting Radiation Safety Officer EXHIBIT b PAGE D OF / PAGE(S) l
I MtNUTES RADIATION SAFETY / RADIOISOTOPE COMMITTEE Thursday, June 14, 1990 MEMBERS PRESENT:
Lawrence H. Flesh, M.D., Chief of Staff S.A. Kang, M.D. Acting Radiation Safety Officer / Chairman Pocheng ?heng, Ph.D. Radiation Therapy Service Paula Hehnings, R.H. Hursing Service .
Min-Fu Tsan, M.D., Ph.D. ACOS, Research and Development An-Ya Wu, M.D. Laboratory Service MEMBERS ABSENT:
Charles A. Hall, M.D. Medical Servite Angel Fermin, M.D. Chief, Radiology Service OLD BUSINESS:
Acceptance of Minutes: Minutes: The minutes from the January 25, 1990, meeting were accepted.
PORTIONS OUTSIDE SCOPE OF REQUEST ON EXHIBIT _M c5 j>n/~. ,
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Status of Recuritment for RSO Vacancy Dr. Kang announced that Dr. Terrance Teslow, who had been offered the RSO position has declined and accepted another position because the salary was unacceptable to him. Among the other applicants, there is a qualified candidate, who has been of f ered the position, pending CO approval.
- 15. A. KANG, M.D.
Chairman / Acting diation Safety Officer i
EXHIBIT &
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.. t MINUTES RADIATION SAFETY / RADIOISOTOPE COMMITTEE September 27, 1990 MEMBERS PRESENT: Dr. Flesh, Dr. Tsan, Dr. Hall, Dr. Kang, Dr. Wu, Dr. Zhang, Dr. Cheng HEMBERS ABSENT: Dr. Termin, Ms. Hemmings OLD DUSINESS:
Agceotance of Minut u: The minutes from the June 14, 1990, meeting were accepted.
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, Introduction of New Radi'ation Safety Officer Dr. Kang introduced James Zhang, the_new Radiation Safety officer.
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05 PORTIONS OUTSIDE SCOPE OF kEQUEST -
Radiation Safety Incident - Lost of Radioactive material Dr. Kang notifled the committee of an-incident occurring on
., August 3, 1990, in which a package containing~1 mci ~of~ -
tritium (Adenosine) was lost. A report-describing the details of this incident was filed with the NRC.
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PORTIONS OUTSIDE SCOPE OF REQUEST (1 5 fEforcement of Radioactive Material Receivina' Procedures The Radiation Safety Cificer noted-that the procedures for signing- off for package receipt when personnel-pick up their RAM orders will be strictly-enforced in the future. He-noted that there have been a few incidents when this was not done,
& !' s S.A. Kang, H.D
-Chai n,RadijtionSafety/RadioisotopeCommittee EXH! BIT b-PAGE k 0F _PAGE(S)
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8 I MINUTES Radiatior.4*afety/ Radioisotope Committee Meeting November 29, 1990 s
Consultant in Attendance! Mr. John Dapolito Hembers Present: Dr. Flesh, Dr. Tsan, Dr. Kang, Dr. Wu, Dr. Silver, Ms Hemmings, Dr. Cheng, Dr. Fereshetlan i
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Penort on NRC Inspection
'Dr. Kang reported to the committee on the recent unscheduled URC inspection on November 21 and 22, 1990. He noted that there were 8ome violations found and reviewed these in detail.
Dr. Tsan noted that there were no deficiencies found in his research lab. He also commented that the lack of a qualified Radiation Safety Officer for the past year to enforce the regulations is the major contributing factor to the problems found in the other research labs.$
Dr. Flesh agreed that the James Zhang did not fulfill the responsibilities of the radiation safety office while he held that position and that the program has not been maintained properly since the Dr. Hill-Zobel resigned in October, 1989. He reported, however, that the NRC lays the blame for that failure on this committee and conveyed the seriousness of this situation which may threaten the hospital's_ broad license. The Director of the NRC Region I office has ordered a board of responsible officials to appear at their office in Pennsylvania to provide a plan to recover from what they estimate is in the order of twenty violations. They have ordered that at that time a complete evaluation of the Radiation Safety Program be provided and EXHlalT /b r ? -- // c -- / R - . -- -
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3 evidence that a Radiation Safety Specialist has been hired.
In addition, they ordered that a complete inventory of scaled sources be provided to their office by December 7.
In the event that a source is not found, a report on the investigation of that loss and corrective actions taken are to be provided. By January 30, 1991, they have ordered that a complete audit of the Radiation Safety Program, in writing, be provided. This must include a written pla?n, eliciting all improvements and violations, staffh- of radiation safety functions, procedures for sealeo 2 .urce inventory control, procedures for Iodine Therapy, procedures for receipt and logging of packages, plans for continued inventory procedures, a plan for training activities and the comprehensive training in radiation safety for all users. They also require that day-to-day oversight of the program be maintained.
Dr. Kang distributed copies of a recent FRC publication which described the responsibilities of L. RS/R Committee and recent punitive actions taken for violations in other medical centers. He also distributed Center Memorandum No.
00-2 Radiation Safety / Radioisotope Committee.
Dr. Tsan noted that other committees who have oversight responsibilities, are required to perform an annual inspection and felt that the responsibilities of this committee shoul.d not be limited to policy making, but should include monito' ring and enforcement as well. Dr. Tsan also felt that it is a- conflict of interest to have the Radiation Safety Office under the Chief of Nuclear Medicine. The committee agreed to discuss this topic at a future meeting.
PORTIONS OUTSIDE SCOPE OF REQUEST
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In closing, the committee members reaffirmed their - -
responsibility to the Radiation Safety Program and will continue an active search for a qualified candidate for Jhe EXH!3lT @
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. PORTIONS OUTSIDE SCOPE OF REQUEST position of Radiation Safety Officer.
S. A. KANG, M.D. b Chairman, Radiation Safety / ioisotope Committee Acting Radiation Safety Offi er APPROVED NwYEU: