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NRC CAL – NOV (SL III)

EA-13-107 · CAL · Severity SLIII · Issued 2013-08-08 · Materials Licensees

Action

EA Number
EA-13-107
Licensee
NOV (SL III)
Category
Materials Licensees
Action type
CAL
Severity level
SLIII
Date issued
2013-08-08

Description

On August 8, 2013, the NRC issued a Notice of Violation to Camden-Clark Memorial Hospital Corporation (CCMHC) for a Severity Level III problem involving two violations. The first violation involved the failure to implement its written procedure to provide high confidence that an administration was performed in accordance with the written directive as required by 10 CFR 35.41. Specifically, on February 25, 2011, CCMHC implanted a patient with 63 palladium-103 seeds to deliver a dose of 125 Gy; however, 16 of the 63 prescribed palladium-103 seeds were implanted outside the planned treatment area. CCMHC's subsequent assessment of the implant on April 1, 2011, did not identify that the delivered dose was different from the prescribed dose by more than 20 percent. This failure to identify the medical event contributed to the second violation, specifically, CCMHC not notifying the NRC Operations Center by the next calendar day, in accordance with 10 CFR 35.3045(c), that a medical event had occurred. Instead, CCMHC reported the medical event on March 5, 2012.

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