NRC Press Release IV12

["Wesley M. Dunn" <WDUNN@brc1.tdh.state.tx.us>]

------------------- iv12.txt follows --------------------

                                                            UNITED STATES
                                             NUCLEAR REGULATORY COMMISSION
                                       OFFICE OF PUBLIC AFFAIRS, REGION IV
                                          611 Ryan Plaza Drive - Suite 400
                                              Arlington, Texas  76011-8064

RIV:      95-12                              FOR IMMEDIATE RELEASE
CONTACT:  Breck Henderson                      February 22, 1996
OFFICE:   817/860-8128
PAGER:    (800) 443-7243 (065477)


          NRC FINES MADIGAN ARMY MEDICAL CENTER $8,000
                 FOR RADIATION TREATMENT ERRORS

     The Nuclear Regulatory Commission has proposed an $8,000
civil penalty against Madigan Army Medical Center (MAMC) in
Tacoma, Wash., for failure maintain the quality assurance program
required to make sure patients receiving radiation therapy were
given proper doses.

     Improper radiation doses were administered to five patients
as a result of the problems, according to an NRC inspection and
investigation conducted from June 6 through December 21, 1995.
The improper doses were the result of using an incorrect
calibration parameter in a computer used to calculate the correct
radiation doses for brachytherapy treatments.

     Brachytherapy involves placing a radioactive source inside a
patient's body next to a tumor or cancerous organ such that the
radiation will aid in the cure.

     The violations were classified as a Severity Level II
problem.  The NRC uses a four level system, with Level I being
the most severe.  Specifically, the NRC cited MAMC for failure to
provide adequate quality management program (QMP) training for
employees involved in its brachytherapy treatment program,
failure to maintain and implement its quality program in a manner
that assured patients would receive prescribed doses, and failure
of MAMC employees to properly check incoming brachytherapy
sources for contamination.

     NRC Regional Administrator L. Joe Callan said, in a letter
to Col. Darrel R. Porr, acting MAMC commander, "These violations
. . . are cause for a very significant regulatory concern because
they are indicative of a substantial programmatic failure to
implement your QMP in a manner that prevented errors in patient
doses, resulting in five patients receiving doses other than the
intended doses."
                             -more-
     The NRC also cited MAMC for the failure of Dr. Hung Yu,
former health physicist at MAMC, to conduct and accurately record
the results of contamination surveys on incoming packages
containing brachytherapy sources.  Mr. Callan pointed out in his
letter that MAMC is responsible the actions of its employees and
for providing the proper training and supervision to make sure
procedures are followed.  This violation was cited as a Severity
Level III problem.

     The NRC noted that, to its credit, MAMC had uncovered these
problems and taken comprehensive corrective actions that included
suspension of the brachytherapy program, review of all treatments
since June 1993 for errors, retraining of employees, third-party
reviews of the brachytherapy program, and counseling and other
disciplinary actions for employees involved in the violations.

     "While the normal civil penalty assessment process would
have resulted in no civil penalty being assessed for either
problem, the NRC has determined that the QMP-related violations,
involving a breakdown in your QMP and resulting in multiple
patient misadministrations, warrant the exercise of discretion
and the assessment of a civil penalty at two times the base
amount for a Severity Level II problem," Mr. Callan said.

     MAMC is required to submit a written statement or
explanation to the NRC within 30 days either admitting or denying
the alleged violations, explaining the reasons for the violations
if admitted or the reasons why denied, corrective steps taken and
results achieved, future corrective steps, and the date when full
compliance will be achieved.  MAMC may pay the civil penalty
during this time or protest it.

     In a related action, the NRC notified Dr. Hung Yu that it is
prepared to relax an order that banned Dr. Hung Yu from
participating in NRC licensed activities.

     Dr. Yu admitted that he had intentionally failed to conduct
required surveys and made false statements to MAMC officials.
However, owing to the circumstances in the case, the
responsibility born by MAMC for training and supervision, the
substantial disciplinary actions already suffered, and Dr. Yu's
statements that he had learned a lesson and would not engage in
similar misconduct in the future, the NRC will relax the order
following receipt of Dr. Yu's certified statement that he has
received training in and will comply with NRC regulations during
future employment in any NRC-licensed activities.
                               ###
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Wesley M. Dunn, C.H.P.                     512-834-6688
Deputy Director, Licensing                 512-834-6690 (fax)
(Texas) Bureau of Radiation Control        wdunn@brc1.tdh.state.tx.us
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