NRC NEWS

 U.S. NUCLEAR REGULATORY COMMISSION

 2443 Warrenville Road

 Lisle IL 60532

 Web Site: http://www.nrc.gov E-mail: opa3@nrc.gov

No. III-05-035 July 20, 2005

CONTACT: Jan Strasma (630) 829-9663 

Viktoria Mitlyng (630) 829-9662 

NRC TO MEET JULY 27 WITH SOUTH BEND, IND., HOSPITAL TO DISCUSS

APPARENT VIOLATIONS ASSOCIATED WITH UNINTENDED RADIATION DOSES

The Nuclear Regulatory Commission staff will meet Wednesday, July 27, in Lisle, Ill., with

officials of St. Joseph Regional Medical Center of South Bend, Ind., to discuss apparent violations of

NRC requirements associated with unintended radiation doses to five patients during treatments last

year.

The hospital reported to the NRC in March 2005 that the patients had received unintended

radiation exposures to their legs during treatment for cervical cancer. The unintended exposures

occurred when a small sealed capsule containing a radiation source shifted during treatment, resulting

in the unintended radiation doses to the skin of each patient’s leg.

The meeting will be at 1 p.m. CDT in the NRC's Region III Office, 2443 Warrenville Rd., Suite

210, in Lisle. The meeting is open to public observation. At the conclusion of the business portion of

the meeting, NRC officials will be available for questions and comments from members of the public

attending the meeting.

Two special NRC inspections have reviewed the incidents and the hospital’s response. NRC

inspectors identified four apparent violations of NRC requirements associated with the unintended

radiation doses.

“This meeting will allow the hospital officials to provide their perspective on the incidents and

describe the measures they have taken to correct the problems and prevent a recurrence,” said James

Caldwell, NRC Regional Administrator. 

“Our inspectors have reviewed the hospital’s radiation therapy program and found that, with

the exception of these five cases, it is complying with NRC requirements,” he said. “The unintended

radiation doses to these five patients occurred under very specific circumstances that have since been

corrected,” he said. 

The four apparent violations, identified during the inspections, included the failure to prepare

adequate procedures, failure to instruct hospital staff in the procedures and requirements, failure to

report the five unintended radiation doses promptly after discovery, and failure to ensure that radiation

safety activities are performed in accordance with procedures and regulatory requirements. A fifth
violation, not associated with the unintended radiation doses, involved the failure to approve a medical

physicist before the individual began work.

The meeting between the NRC staff and the hospital, called a predecisional enforcement

conference, is an opportunity for the hospital to provide its perspective on the apparent violations and

to offer any other information that they believe the NRC should take into consideration in making an

enforcement decision. No decision on the apparent violations or any enforcement action will be made

at the conference. Those decisions will be made later by NRC officials.

The inspection report describing the apparent violations is available from the Region III Office

of Public Affairs or from the agency's online document library (known as ADAMS): 

http://www.nrc.gov/reading-rm/adams/web-based.html - use accession number ML051750196 in the

search box to locate the report. For assistance in using ADAMS, you may contact the NRC Public

Document Room staff at 800/397-4209.

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