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23 May 2008
[Federal Register: May 23, 2008 (Volume 73, Number 101)]
[Notices]
[Page 30169-30173]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr23my08-121]
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NUCLEAR REGULATORY COMMISSION
Report to Congress on Abnormal Occurrences, Fiscal Year 2007;
Dissemination of Information
Section 208 of the Energy Reorganization Act of 1974 (Pub. L. 93-
438) defines an abnormal occurrence (AO) as an unscheduled incident or
event which the U.S. Nuclear Regulatory Commission (NRC) determines to
be significant from the standpoint of public health or safety. The
Federal Reports Elimination and Sunset Act of 1995 (Pub. L. 104-68)
requires that AOs be reported to Congress annually. During Fiscal Year
2007, eleven events that occurred at facilities licensed or otherwise
regulated by the NRC and/or Agreement States were determined to be AOs.
The report describes five events at NRC-licensed facilities. The first
NRC-licensee event involved radiation exposure to an embryo/fetus. The
other four NRC-licensee events were medical events, as defined in Title
10, Part 35, of the Code of Federal Regulations (10 CFR part 35). All
five NRC-licensee events occurred at medical institutions. The report
also describes six events at Agreement State-licensed facilities.
[Agreement States are those States that have entered into formal
agreements with the NRC pursuant to Section 274 of the Atomic Energy
Act (AEA) to regulate certain quantities of AEA licensed material at
facilities located within their borders.] Currently, there are 34
Agreement States. All six events that occurred at Agreement State-
licensed facilities were medical events, as defined in 10 CFR Part 35,
and occurred at medical institutions. As required by Section 208, the
discussion for each event includes the date and place, nature and
probable consequences, the cause or causes, and the actions taken to
prevent recurrence. Each event is also being described in NUREG-0090,
Vol. 30, ``Report to Congress on Abnormal Occurrences: Fiscal Year
2007.'' This report is available electronically at the NRC Web site
http://www.nrc.gov/reading-rm/doc-collections/nuregs/staff/.
I. For All Licensees
A. Human Exposure to Radiation From Licensed Material
During this reporting period, one event at an NRC-licensed and
regulated facility was significant enough to be reported as an abnormal
occurrence (AO).
NRC07-01 Human Exposure to Radiation at Washington University Medical
Center in St. Louis, Missouri
Date and Place--May 29, 2007, St. Louis, Missouri.
Nature and Probable Consequences--Washington University Medical
Center (the licensee) reported that cancer treatment to a 22 year old
patient using iodine-131 resulted in a dose to an embryo/fetus. On May
29, 2007, the treatment was conducted at Barnes Jewish Hospital, the
affiliated teaching hospital of Washington University School of
Medicine, using 4.64 GBq (126 mCi) of iodine-131. Prior to that
[[Page 30170]]
treatment, the patient saw her prescribing physician on May 22, 2007,
for a related consultation. In addition, because hospital procedures
require a pregnancy test within 1 week before the therapy is
administered, the licensee conducted a pregnancy test on the patient on
the same day. That test yielded a negative result and the patient was
advised not to get pregnant prior to the treatment. Moreover, before
treatment on May 29, 2007, the patient signed a statement that, to the
best of her knowledge, she was not pregnant. However, on May 30, 2007,
the patient performed a home pregnancy test, which yielded a positive
result. Consequently, the licensee performed another pregnancy test the
same day, and the results indicated that the patient had been pregnant
for 4-5 weeks at the time of the iodine-131 administration. The patient
and the referring physician were informed of this event. As an
approximation for the dose equivalent received by the embryo/fetus, the
licensee's staff calculated an annual total effective dose equivalent
to the patient's uterus, which was estimated to be 250-340 mSv (25-34
rem).
The NRC-contracted medical consultant confirmed the licensee's dose
estimate and determined that the most likely result would be delivery
of a normal infant (with regard to thyroid function) because the
iodine-131 was administered at such an early stage in the pregnancy;
however, the risk of childhood cancer may be slightly increased. The
possible effects of the event have been discussed with the patient.
Cause(s)--The causes of this event were the false negative
pregnancy test and the patient's lack of awareness that she might be
pregnant.
Actions Taken To Prevent Recurrence
Licensee--Because the causes of this event were beyond the
licensee's control, the licensee determined that no corrective action
was necessary to prevent recurrence.
NRC--There were no violations identified by the NRC.
II. Commercial Nuclear Power Plant Licensees
During this reporting period, no events at commercial nuclear power
plants in the United States were significant enough to be reported as
AOs.
III. Events at Facilities Other Than Nuclear Power Plants and All
Transportation Events
C. Medical Licensees
During this reporting period, four events at NRC-licensed or
regulated facilities and six events at Agreement State-licensed
facilities were significant enough to be reported as AOs.
NRC07-02 Medical Event at St. Luke's Hospital of Kansas City, Missouri
Date and Place--October 23-26, 2006, Kansas City, Missouri.
Nature and Probable Consequences--On October 27, 2006, St. Luke's
Hospital of Kansas City (the licensee) notified the NRC of a medical
event that occurred during a high dose-rate (HDR) remote afterloader,
using a 144 GBq (3.9 Ci) iridium-192 source, brachytherapy procedure to
treat breast cancer.
The authorized user physician developed a written directive that
prescribed 10 fractionated doses, to be administered to the patient's
left breast using a balloon catheter technique, with each dose
consisting of 3.4 Gy (340 rad), for a total dose of 34 Gy (3,400 rad).
The first fractionated dose was administered to the patient on October
23, 2006. On October 26, 2006, after the seventh fraction and prior to
administering the eighth fraction to the patient, the chief physicist
noted a discrepancy. The investigation into the discrepancy revealed
that the catheter length entered into the treatment planning computer
was 93.0 cm (36.6 in), rather than 95.0 cm (37.4 in). This error
resulted in delivering an unplanned dose of 100 Gy (10,000 rad), 1.0 cm
(0.4 in) from the treatment site and proximal from the balloon. The
area proximal from the balloon would have received an intended dose of
24.5 Gy (2,450 rad), had the treatment been delivered as prescribed by
the authorized user physician. Moreover, because the prescribed dosage
was not delivered to the correct location, the patient also received an
under dosage to the distal side of the balloon. Specifically, the area
intended to be treated received a dose in the range of 7 Gy to 10 Gy
(700 rad to 1,000 rad) rather than the prescribed dosage of 34 Gy
(3,400 rad). The patient and the referring physician were informed of
this event. The authorized user physician did not expect any acute
adverse medical effects to the patient as a result of the medical
event, but indicated that surgery may be required in the future. The
authorized user physician discontinued further treatments and plans to
follow-up on the patient clinically.
The NRC-contracted medical consultant expects some necrosis to
fatty tissue in the overexposed region of the breast, within 2-4
months.
Cause(s)--The medical event was caused by the dosimetrist's failure
to enter the correct catheter length in preparing the treatment plan
parameters for the HDR brachytherapy treatment. In addition, the
licensee's written procedures for implementing HDR treatment plans did
not require verification of the treatment plan parameters to ensure
that they were correct.
Actions Taken To Prevent Recurrence
Licensee--The licensee initiated several immediate and long-term
corrective actions to prevent recurrence. Specifically, those
corrective actions included (1) Revising the procedures for HDR
treatments to include verification of the catheter length and input to
the treatment planning computer by both the medical physicist and the
authorized user physician, (2) revising the treatment plan record to
require that the authorized user physician and the medical physicist
document the verification of the catheter length, and (3) conducting
in-house training to ensure that staff are aware of the new procedural
steps and to ensure that the prescribing authorized user physician and
the medical physicist actively participate in the training.
NRC--On March 14, 2007, the NRC issued a Notice of Violation
related to this event.
NRC07-03 Medical Event at Hackley Hospital in Muskegon, Michigan
Date and Place--January 8, 2007, Muskegon, Michigan.
Nature and Probable Consequences--On January 8, 2007, Hackley
Hospital (the licensee) notified the NRC of a medical event that
occurred during a brachytherapy seed implant procedure to treat
prostate cancer. The written directive prescribed a total dose of 120
Gy (12,000 rad) to the patient's prostate using 41 iodine-125 seeds as
permanent implants. According to the licensee, because the patient
moved, only 7 of the prescribed 41 seeds were delivered to the prostate
(the intended site), and the other 34 seeds were delivered to an
unintended site located approximately 4 cm (1.6 in) inferior to the
prostate. As a result, the prostate received a dose of approximately 13
Gy (1,300 rad) rather than the prescribed dose of 120 Gy (12,000 rad)
(~90% less than the prescribed dose). In addition, the unintended site
received a dose of approximately 110 Gy (11,000 rad) and the patient's
skin around the
[[Page 30171]]
unintended site received a dose of approximately 2.4 Gy (240 rad). The
patient and the referring physician were informed of this event. The
patient will require further treatment via external beam therapy in
order to deliver the appropriate dose to the prostate.
The NRC-contracted medical consultant agreed with the licensee's
dose estimate and concluded that the risk for impotence is somewhat
increased by the additional radiation dose to the unintended site as a
result of the medical event. There may also be some risk of perineal
tissue fibrosis and skin irritation, although the risk may not be
significant enough to cause clinical concerns.
Cause(s)--The licensee determined the root cause of the event was a
failure to identify the patient's movement before continuing with the
procedure. In addition, the NRC inspector determined that the licensee
failed to develop adequate written procedures to provide high
confidence that each brachytherapy administration was in accordance
with the authorized user physician's written directive, as required by
10 CFR 35.41. Specifically, the licensee's procedures did not include
appropriate steps or guidance to ensure that radioactive sources were
positioned in the patient in accordance with the written directive and
treatment plan.
Actions Taken To Prevent Recurrence
Licensee--The licensee's corrective actions to prevent recurrence
included revising its written procedure to ensure that sources are
positioned in the patient in accordance with the written directive, and
ensuring that the staff implements those revisions.
NRC--On June 20, 2007, the NRC issued a Notice of Violation related
to this event.
* * * * *
NRC07-04 Medical Event at Kennedy Memorial Hospital in Turnersville,
New Jersey
Date and Place--October 25, 2006 (identified on December 8, 2006),
Turnersville, New Jersey.
Nature and Probable Consequences--Kennedy Memorial Hospital (the
licensee) reported that a patient was prescribed a brachytherapy
treatment of 145 Gy (14,500 rad) to the prostate gland for prostate
cancer using 104 iodine-125 seeds, but instead received a dose of 145
Gy (14,500 rad) to an unintended treatment site. The brachytherapy
seeds were implanted under ultrasound guidance; however, a post-
treatment computed tomography scan showed that the implanted seeds were
displaced inferior to the intended position, resulting in a dose of
approximately 8 Gy (800 rad) delivered to the intended treatment site.
The patient and the referring physician were informed of this event,
and additional external beam radiation treatment was recommended.
The NRC staff conducted a reactive onsite inspection on December
12, 2006. The NRC-contracted medical consultant reviewed the case and
agreed with the licensee's analysis and conclusions, stating that no
significant adverse health effect to the patient is expected.
Cause(s)--The medical event was caused by the licensee's failure to
accurately identify the position of the prostate during the
intraoperative ultrasound guidance procedure.
Actions Taken to Prevent Recurrence
Licensee--The licensee revised its procedures, including the use of
a contrast medium in the Foley catheter balloon to more clearly
identify the bladder/prostate interface, and use of fluoroscopic
imaging to confirm anatomical positioning and verify seed placement.
NRC--There were no violations identified by the NRC.
NRC07-05 Medical Event at the University of Virginia at
Charlottesville, Virginia
Date and Place--February 2-4, 2007, Charlottesville, Virginia.
Nature and Probable Consequences--University of Virginia at
Charlottesville (the licensee) reported that a patient was prescribed a
brachytherapy treatment of 30 Gy (3,000 rad) for treatment of cancer of
the cervix using cesium-137 sources. Instead, the patient received 7.7
Gy (770 rad) to the cervix and small volumes of the rectum and vaginal
mucosa received doses greater than intended, ranging from 14.14 Gy to
26.77 Gy (1,414 rad to 2,677 rad). Upon removal of the implant, the
licensee discovered that the applicator had been loaded with a plastic
radioactive source carrier insert that was approximately 4 cm (1.6 in)
shorter than the intended 24 cm (9.5 in) insert, which caused the
sources to be displaced from the intended position. The patient and the
referring physician were informed of this event, and additional
external beam radiation treatment was recommended.
The NRC staff conducted a reactive onsite inspection on February
12, 2007. The NRC-contracted medical consultant reviewed the case and
agreed with the licensee's analysis and conclusions, stating that no
significant adverse health effect to the patient is expected.
Cause(s)--The medical event was caused by the licensee's failure to
ensure that the insert was of the correct length before preloading the
cesium-137 sources.
Actions Taken To Prevent Recurrence
Licensee--The licensee revised its procedures, including measuring
the length of the insert before loading the source, and limiting the
supply of inserts in the source loading room to inserts of the length
used for standard applicator treatments. The licensee also implemented
additional staff training.
NRC--On May 7, 2007, the NRC issued a Notice of Violation related
to this event.
AS07-01 Medical Event at St. James Hospital and Health Center in
Olympia Fields, Illinois
Date and Place--November 29, 2006--December 20, 2006, Olympia
Fields, Illinois.
Nature and Probable Consequences--St. James Hospital and Health
Center (the licensee) reported that a 75-year-old female patient
received a dose to an unintended area of approximately 4 cm2
(0.6 in2) of 20 Gy (2,000 rad), which was prescribed to
supplement surgery and external radiation treatments for cancer of the
uterus. The treatment used a high dose-rate (HDR) afterloader
containing an iridium-192 source with an activity of 370 GBq (10 Ci).
The source stopped 20 cm (7.9 in) short of the intended position; thus,
the patient received none of the prescribed dose to the correct
location. The patient and the referring physician were informed of this
event. Over the next 4 weeks, the patient was treated for wet
desquamation on both of her inner thighs, surrounded by a halo of
erythema and the licensee continues to monitor the patient.
Cause(s)--The medical event was caused by human error. The licensee
entered an incorrect initial value into the treatment system, and the
treatment plan was not reviewed by an authorized medical physicist
during the subsequent three weekly treatment sessions. The error was
identified during a chart audit before the next similar HDR treatment
was planned.
Actions Taken To Prevent Recurrence
Licensee--The licensee reviewed previous administrations to confirm
that this event was an isolated incident. The licensee also developed
new procedures requiring additional quality assurance steps, including
the presence of a medical physicist during treatments. In addition,
licensee personnel received additional training on the revised
treatment procedures.
State--The State conducted an investigation on January 8, 2007, and
[[Page 30172]]
issued a Notice of Violation. On March 8, 2007, the NRC-contracted
medical consultant investigated the matter for the State and supported
the licensee's conclusions. The State accepted the licensee's
corrective actions on April 12, 2007.
AS07-02 Medical Event at Aroostook Medical Center of Presque Isle,
Maine
Date and Place--January 16, 2007, Presque Isle, Maine.
Nature and Probable Consequences--Aroostook Medical Center (the
licensee) reported that a patient received 148 MBq (4 mCi) of iodine-
131 for a whole body scan, instead of the prescribed 5.6 MBq (0.151
mCi) for a thyroid uptake scan. On March 6, 2007 during a follow-up
visit with an endocrinologist, it was recognized that the wrong scan
was performed. The patient and the referring physician were informed of
this event. Using the methodology in NUREG-CR-6345, ``Radiation Dose
Estimates for Radiopharmaceuticals'', the licensee estimated that the
administration of 148 MBq (4 mCi) resulted in a thyroid dose of 51.22
Sv (153.7 rem). The licensee concluded that no significant adverse
health effect to the patient is expected.
Cause(s)--The medical event was caused by human error. The licensee
failed to verify the prescribed dosage for a specific patient directly
with the referring physician. In addition, a written directive was not
completed for this procedure.
Actions Taken To Prevent Recurrence
Licensee--Corrective actions taken by the licensee included
revising procedures to improve communication with referring physicians,
to allow the certified nuclear medicine technologist to speak directly
with the referring physician or authorized user to confirm the type of
test to be conducted. Also, written directives will be required for all
administrations of iodine-131 in quantities greater than 1.11 MBq (30
[mu]Ci).
State--The State Radiation Control Program (RCP) performed an
onsite investigation on May 24, 2007, and requested that the licensee
take corrective actions to prevent recurrence. The RCP initially
reviewed and accepted the licensee's proposed corrective actions during
this investigation. The RCP issued a Notice of Violation on November 1,
2007, and awaits the licensee's response.
AS07-03 Medical Event in New York
Date and Place--March 7, 2007; (Licensee) New York.
Nature and Probable Consequences--The licensee reported a
brachytherapy medical event to the New York State Department of Health.
The event involved a 31-year-old female patient with a history of
vaginal cancer. The treatment involved the use of both cesium-137 and
iridium-192 seeds. Each ribbon contained 8 seeds with an activity of
1.855 milligram radium equivalent (118 MBq or 3.19 mCi). The patient
was to be administered a total dose of 25 Gy (2,500 rad) via
interstitial brachytherapy, to be delivered to the 0.5 Gy (50 rad)
isodose line for a total treatment time of 50 hours.
On March 6, 2007, the iridium-192 seeds and the cesium-137 seeds
were placed into the patient. Late in the morning of March 7, 2007, the
medical physicist performed a manual check of the treatment plan
calculations, and discovered that the hand calculations indicated a
significantly higher dose rate than was generated using the treatment
planning software. The ensuing investigations revealed that the
original treatment plan was in error. On March 7, 2007, after 27 hours
of treatment, the seeds were removed from the patient.
The patient received an estimated dose of 45.9 Gy (4,590 rad) to
the treatment site, rather than the intended 25 Gy (2,500 rad). The
rectal dose was 73 Gy (7,300 rad). The radiation oncologist disclosed
that the patient is at risk for radiation cystitis, rectal proctitis,
and more importantly, fistula formation between the rectum and the
vagina. The patient and the referring physician were informed of this
event. The patient will be monitored closely over the next year by both
her gynecologic oncologist and the radiation oncologist. The patient is
being treated with broad spectrum antibiotics, along with daily
treatments in a hyperbaric oxygen chamber.
Cause(s)--The primary cause was the use of an inappropriate Dose
Rate Factor (DRF) in the treatment planning system. The value used
corresponded to the DRF for air kerma, however, the seed strength
entered was in milligram radium equivalent. Other causes and
contributing factors included failure to check the treatment pre-plan
before the seeds arrived although there was time to do so; failure to
double-check the calculations either prior to the implant or shortly
thereafter; use of a treatment planning system that underwent
acceptance testing for cesium-137 and iodine-125, but not iridium-192;
and lack of recent experience preparing a treatment plan using iridium-
192. Neither the physicist nor the radiation oncologist had prepared a
treatment plan using iridium-192 in 6 years.
Actions Taken To Prevent Recurrence
Licensee--The licensee changed its policy and procedures to require
a check of calculations for any single-fraction brachytherapy
treatment.
State--The State plans to follow-up on the licensee's
implementation of their new procedures during the next regularly
scheduled inspection.
AS07-04 Medical Event at Memorial Mission Hospital of Asheville, North
Carolina
Date and Place--April 24, 2007, Asheville, North Carolina.
Nature and Probable Consequences--Memorial Mission Hospital (the
licensee) reported that a 19-year-old female patient was prescribed a
dose of 1.24 MBq (33.4 [mu]Ci) of iodine-131 for a diagnostic scan to
assess the health of her thyroid, however, she was administered a dose
of 1235.8 MBq (33,400 [mu]Ci) on April 24, 2007. The licensee
discovered the event when the patient returned the next day for her
uptake scan. The patient was placed on a gamma camera and given a whole
body scan. The spectrum was identified as iodine-131 and the uptake was
concentrated in the patient's neck area, consistent with a thyroid
uptake. As a result, the patient received a dose to the thyroid of
approximately 287.3 Gy (28,728 rad). The patient and the referring
physician were informed of this event.
The patient received an ablative quantity of radioactive iodine and
initially showed classic signs of thyroidoitis, including inflammation,
swelling, pain, and difficulty swallowing. The patient has recently
started taking a synthetic thyroid hormone.
Cause(s)--The radiopharmacy provided the hospital an incorrect and
mislabeled dose. The hospital failed to conduct a proper and accurate
receipt survey on the package when it arrived in the hospital's nuclear
medicine department. The nuclear medicine technologist, who performed
the package receipt survey, failed to investigate the higher-than-
expected dose rate off the transport container to determine if anything
unusual was present. The nuclear medicine technologist assigned to the
patient failed to correctly and accurately assay the dose in the dose
calibrator. A second nuclear medicine technologist who is supposed to
perform a quality assurance (QA) check of the dose calibrator reading,
taken by the nuclear medicine technologist assigned to the patient,
failed to correctly and accurately read the dose calibrator. The
nuclear
[[Page 30173]]
medicine technologist assigned to the patient failed to recognize that
the number of counts obtained from the neck phantom used for the uptake
scan baseline was unusually high for the quantity of radioactive
material prescribed for the patient.
Actions Taken To Prevent Recurrence
Licensee--The licensee ceased purchasing radiopharmaceuticals from
the radiopharmacy that provided the incorrect and mislabeled dose. The
licensee set aside a designated area for receiving shipments of
radiopharmaceuticals and posted a list of expected dose rates per
shipment (based upon contents of the shipment). The licensee redesigned
the patient administration log to serve as a check list for QA,
instituted procedural changes to include a one-meter survey of each
diagnostic capsule while it is being counted in the neck phantom prior
to administration, and implemented updated training to acquaint all
nuclear medicine technologists with these new policies.
State--The State radiation control agency conducted an
investigation into this incident assisted by the State board of
pharmacy. The licensee's actions to prevent recurrence will be
inspected at their next regularly scheduled inspection.
AS07-05 Medical Event at University of Washington Harborview Gamma
Knife of Seattle, Washington
Date and Place--November 16, 2006, Seattle, Washington.
Nature and Probable Consequences--University of Washington
Harborview Gamma Knife (the licensee) reported that a patient who was
prescribed to receive 18 Gy (1,800 rad) during a gamma knife treatment
actually received 28 Gy (2,800 rad). The gamma knife contained 267.7
TBq (7,236 Ci) of cobalt-60. The patient and the referring physician
were informed of this event. The licensee concluded that no significant
adverse health effect to the patient is expected.
Cause(s)--The cause of the incident was determined to be human
error. The prescribing physician prescribed 18 Gy (1,800 rad) and
erroneously entered 28 Gy (2,800 rad). The physician entered the
prescribed value into the computer treatment planning system, rather
than having the medical physicist enter the value as is the usual
procedure, resulting in a failure to follow an established procedure.
Actions Taken To Prevent Recurrence
Licensee--Corrective actions taken by the licensee included a
verification process to ensure that the prescribed treatment value is
transferred from the treatment planning computer to the gamma knife
computer prior to patient therapy. Also, a treatment plan signed by the
treating oncologist, physicist, and neurosurgeon is now required. In
addition, the treating oncologist and physicist will verify and initial
the prescribed dose and isodose treatment parameters prior to patient
therapy.
State--The State reviewed the licensee's corrective actions and
determined that the procedures were adequate to ensure that this type
of event should not happen in the future.
AS07-06 Medical Event at Physician Reliance of Fort Worth, Texas
Date and Place--August 22, 2007, Fort Worth, Texas.
Nature and Probable Consequences--Physician Reliance (the licensee,
dba Texas Oncology at Klabzuba) reported that a patient who was being
treated for lung cancer, with a high dose-rate (HDR) afterloader and an
iridium-192 source, received 2,500 cGy (2,500 rad) during the first
fraction, instead of the prescribed dose of 500 cGy (500 rad). The
patient was prescribed to receive five fractions with 500 cGy (500 rad)
per fraction over five weeks. The incident was discovered following an
independent physicist's review of the treatment plan. The patient and
the referring physician were informed of this event. The patient's
pulmonologist concluded that no significant adverse health effect to
the patient is expected.
Cause(s)--The incident occurred as a result of the incorrect
isodose line being chosen and entered into the treatment planning
system. The oncologist signed and approved the treatment plan and the
radiation safety office performed a second calculation to check the
treatment plan. The treatment planning system then normalized the
calculations to the incorrect isodose line and delivered the resulting
treatment. The calculation error was identified by an independent
physicist prior to administration of the second fraction.
Actions Taken To Prevent Recurrence
Licensee--The licensee's corrective action was to change their
procedure to include a second check by a licensed medical physicist of
all treatment plans.
State--The State issued two violations related to this event: (1) A
violation of 25 Texas Administrative Code (TAC) 289.256(p)(4)(A) and
(B) was cited because the procedure as implemented was insufficient to
ensure that a second check of the printed output of the treatment plan
was performed to verify the accuracy of the planned treatment factors
prior to treatment; and (2) a violation of 25 TAC 289.256(o)(1) and
289.256(p)(1) was cited because the instructions of obtaining the
authorized physician's signed and dated written directive for each
therapeutic administration were not followed. In addition, the State
reviewed the licensee's corrective action of changing their procedures
to include a second check by a licensed medical physicist of all
treatment plans.
Dated at Rockville, Maryland, this 19th day of May 2008.
For the U.S. Nuclear Regulatory Commission.
Annette L. Vietti-Cook,
Secretary of the Commission.
[FR Doc. E8-11666 Filed 5-22-08; 8:45 am]
BILLING CODE 7590-01-P