RE: NRC PROPOSES $6,000 FINE AGAINST ST. JOSEPH MERCY HOSPITAL IN MICHIGAN FOR OVEREXPOSURE TO A MEMBER OF THE PUBLIC

["Shackford, Hobart W" <hshackford@rwmc.org>]

I think it is informative to get more specific details on this incident. I

was surprised at the 3-15 rem dose level and could not understand how that

could happen but then when I found out the adminstered activity was 285

mCi.... The notice of violation is at:

http://www.nrc.gov/reading-rm/doc-collections/enforcement/actions/materials/

ea02248.html



The interesting paragraphs are below. And yes, I think the RSO's feet should

be held to the fire. I don't think the NRC's expectations are unreasonable.



Hobie Shackford

Roger Williams Medical Center

Providence, RI





Specifically, for the period from July 1 through July 7, 2002, a member of

the public received a total effective dose equivalent between 3 and 15 rem.

The individual received the exposure while visiting a relative who had been

administered a radiopharmaceutical therapy dosage of 285 millicuries of

sodium iodide iodine-131. The individual received the exposure as a result

of not following prescribed radiation safety instructions, including staying

behind the shielding. Hospital staff frequently noted the individual sitting

at the patient's bedside where a shield was not located. When this was

observed, the hospital staff reminded the individual to position herself on

the other side of the bed behind shielding. While the member of the public

disregarded radiation safety instructions provided by hospital staff, the

radiation safety officer failed to implement corrective actions as necessary

to minimize the individual's exposure, once the extent of the potential

exposure was identified. 



During the predecisional enforcement conference, you stated that you did not

take more proactive steps to limit the dose to visitors or to contact the

patient's relatives to more accurately determine their dose because of your

concern for the patient's rights and for compassion toward the patient and

family members. The NRC staff understands that the case involved unusual

circumstances and that you did not want to appear uncompassionate toward the

patient or her family. However, you could easily have implemented a number

of actions in response to the daughter not following instructions, such as:

(1) explaining to the daughter that staying an arm's length from the patient

would significantly reduce the exposure (radiation levels at one meter were

approximately one-tenth those at the bedside); (2) using additional

shielding, including shielding the catheter bag; (3) minimizing the

daughter's time at the bedside; and (4) providing a digital dosimeter for

the daughter to self-monitor her exposure, which you had available.

Therefore, the NRC has determined that your staff's performance was

deficient such that enforcement action is warranted.



Although the NRC's medical consultant indicated that the radiation exposure

received by this individual is not significant from a health and safety

standpoint, the NRC considers any exposure in excess of regulatory limits a

significant matter. The NRC expects licensees to conduct their operations in

a manner that precludes such exposures from exceeding the limits established

in 10 CFR Part 20. In this case, the exposure to the individual was well in

excess of the regulatory limit. Therefore, these violations are categorized

collectively in accordance with the "General Statement of Policy and

Procedure for NRC Enforcement Actions" (Enforcement Policy), NUREG-1600 as a

Severity Level I problem. 

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