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NRC ORDER – NOVCP (SL III) $14,000

EA-10-023 · ORDER · Severity SLIII · Issued 2010-06-02 · Materials Licensees

Action

EA Number
EA-10-023
Licensee
NOVCP (SL III) $14,000
Category
Materials Licensees
Action type
ORDER
Severity level
SLIII
Date issued
2010-06-02

Description

On June 2, 2010, the NRC issued a Notice of Violation and Proposed Imposition of Civil Penalty in the amount of $14,000 to the Department of Veterans Affairs for two Severity Level III violations identified as a result of a medical event that occurred at the San Diego Healthcare System facility. The medical event resulted when iodine-131 was injected into the wrong port of the gastrostomy feeding tube (g-tube) resulting in an underdose to the patient's thyroid and an unintended dose to the patient's stomach. Specifically, the licensee's written procedures did not include directions for administering byproduct material through a g-tube to ensure that the administered dose was in accordance with the written directive as required by 10 CFR 35.41(a)(2). Additionally, two nuclear medicine technologists had not been instructed on administering byproduct material through a g-tube prior to performing the administration in order to ensure that the administered dose was in accordance with the written directive. The second Severity Level III violation involved the licensee's failure to notify the NRC Operations Center no later than the next calendar day after discovery of a medical event as required by 10 CFR 35.3045(c). Specifically, on September 23, 2009, the licensee had sufficient information, based on patient survey data and the image from the nuclear medicine department, to report the medical event and did not notify the NRC until September 26, 2009.

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