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NRC CAL – NOV (SL III)

EA-14-236 · CAL · Severity SLIII · Issued 2015-03-09 · Materials Licensees

Action

EA Number
EA-14-236
Licensee
NOV (SL III)
Category
Materials Licensees
Action type
CAL
Severity level
SLIII
Date issued
2015-03-09

Description

On March 9, 2015, the NRC issued a Notice of Violation to Beaumont Health System for a Severity Level III violation involving the failure to develop, implement, and maintain written procedures to provide high confidence that each administration was in accordance with the written directive as required by 10 CFR 35.41(a). In accordance with 10 CFR 35.41(b)(2), the procedures required by 10 CFR 35.41(a) must address verifying that the administration is in accordance with the treatment plan, if applicable, and the written directive. Specifically, on October 30, 2014, the licensee administered yttrium-90 to the posterior portion of the right lobe of a patient’s liver, and the licensee’s procedures did not require verification that the dose was in accordance with the applicable treatment plan and written directive. As a result, a medical event occurred as the patient received a dose that was 20.8 percent more than the prescribed dose.

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