U.S. Nuclear Regulatory Commission

Office of Public Affairs, Region II

61 Forsyth Street, Suite 23T85

Atlanta, GA 30303

No: II-98-2 FOR IMMEDIATE RELEASE

Contact: Ken Clark or Roger Hannah (Thursday, January 8 1998)

NRC SCHEDULES CONFERENCE IN PUERTO RICO

ON RADIATION SAFETY AT HOSPITAL METROPOLITANO

The Nuclear Regulatory Commission staff has scheduled a predecisional

enforcement conference on January 13 at Hospital Metropolitano in Rio Piedras, Puerto

Rico to discuss with hospital officials concerns related to apparent violations of NRC safety

requirements associated with use of radioactive material for treatment of patients.

NRC inspections at the hospital last September 24 and October 21 resulted in

identification of apparent violations related to (1) failure to control and maintain constant

surveillance over licensed, radioactive material and (2) multiple instances of failure to

promptly inventory radioactive material after use.

On May 18, 1996, a physician unfamiliar with new equipment temporarily lost a 7.6

millicurie Cesium-137 radioactive source at 12:45 a.m. following treatment of a patient.

The patient was discharged from the hospital the same day at 10:30 a.m., but the source

remained on the floor of the room for 55 hours before being identified as lost and

recovered on May 20. Hospital records indicate personnel entries to the room prior to

recovery of the source were of short duration by the nursing and housekeeping staff. The

hospital estimates that radiation levels at the patient’s bed were at 1.3 millirem per hour,

and the maximum estimated exposure for the hospital staff was 9.3 millirem to the whole

body.

The physician apparently failed to account for the lost source immediately because

of unfamiliarity with the new equipment, and a technologist did not discover the mistake

until May 20 while conducting an inventory.

Federal regulations require that promptly after removal from a patient, radioactive

sources must be returned to their storage area and counted to assure that all have been

returned. The NRC inspector’s review of therapy records indicated that the licensee had

failed on five other occasions to promptly inventory radioactive sources after patient

treatment. No other indications of material being lost were found.

The enforcement conference will begin at the hospital, located at Carretera 21, No.

1785, URB.Las Lomas, Rio Piedras, at 9:00 a.m. It is open to observation by members

of the public and the press. NRC officials will be available at its conclusion to answer
questions from interested observers.

The decision to hold the conference does not mean that a determination has been

made that a violation has occurred or that enforcement action will be taken. The purpose

is to discuss apparent violations along with their causes and safety significance, to provide

the licensee an opportunity to point out errors that may have been made in NRC inspection

reports, and to enable the company to outline its proposed corrective actions.

No decisions on enforcement action will be made at the conference. NRC officials

will decide at a later time whether escalated enforcement action, such as a civil penalty,

is appropriate.