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RIII-99-49

December 10, 1999

NRC Staff Issues Confirmatory Order to Medical Technologist For Deliberate Misconduct at Michigan Hospital

The Nuclear Regulatory Commission staff has issued a confirmatory order to a medical technologist at the MidMichigan Medical Center, Midland, Michigan, as a result of deliberate misconduct associated with administering radiation therapy to a patient.

The Order, issued to John Urban, requires that, should he seek other employment in NRC-licensed activities during the next two years, he provide a copy of the Order to a prospective employer. If he accepts employment in NRC-licensed activities, he is required to notify the NRC. Mr. Urban has agreed to the terms of the Order.

An NRC investigation determined that Mr. Urban had administered the incorrect radiation dosage to a patient being treated for thyroid cancer on May 24. The patient was to receive a 150-millicurie dose of radioactive iodine-131. Mr. Urban did not review the physician's written directive for the procedure and administered a prepared dose of approximately 100 millicuries.

When he discovered the error, he altered the written directive, changing the intended dosage from 150 millicuries to 100 millicuries. Two days later, the patient's physician discovered that the written directive had been changed.

The physician reviewed the lower dosage and determined that no additional treatment was required. The patient's condition will continue to be monitored.

On June 1, the hospital notified the NRC of the error in the dose administered. Subsequently, Mr. Urban provided inaccurate and incomplete information to an NRC inspector, denying that he had changed the written directive.

He also failed to inform hospital management of the error, and, as a result, the hospital did not report the medical misadministration to the NRC in a timely manner, as required.

"The NRC must be able to rely on the Licensee and its employees to comply with NRC requirements," the Order to Mr. Urban states. "Mr. Urban's actions have raised serious doubt as to whether he can be relied upon to comply with NRC requirements and provide complete and accurate information to the NRC."

In addition to the Confirmatory Order to Mr. Urban, the NRC issued a Notice of Violation to the MidMichigan Medical Center for violations associated with Mr. Urban's actions. A fine of $2,750 was considered for the violations, but no fine was proposed because the hospital discovered the violations and took comprehensive corrective actions.

Mr. Urban remains employed by the hospital. During the next two years, the hospital has committed to having all work performed by Mr. Urban in NRC-licensed activities supervised and checked by another technologist.

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