N.M. Admin. Code § 20.3.7.716

Current through Register Vol. 35, No. 21, November 5, 2024

Section 20.3.7.716 - REPORTS

A.Report and notification of a medical event.

(1) A licensee shall report any event, except for an event that results from patient intervention, in which the administration of byproduct material or radiation from byproduct material, except permanent implant brachytherapy, results in:

(a) a dose that differs from the prescribed dose or dose that would have resulted from the prescribed dosage by more than 5 rems (50 millisieverts) effective dose equivalent, 50 rems (0.5 sievert) to an organ or tissue or 50 rems (0.5 sievert) shallow dose equivalent to the skin; and:

(i) the total dose delivered differs from the prescribed dose by twenty percent or more;

(ii) the total dosage delivered differs from the prescribed dosage by twenty percent or more or falls outside the prescribed dosage range; or

(iii) the fractionated dose delivered differs from the prescribed dose, for a single fraction, by fifty percent or more;

(b) a dose that exceeds 5 rems (50 millisieverts) effective dose equivalent, 50 rems (0.5 sievert) to an organ or tissue, or 50 rems (0.5 sievert) shallow dose equivalent to the skin from any of the following:

(i) an administration of a wrong radioactive drug containing byproduct material;

(ii) an administration of a radioactive drug containing radioactive material by the wrong route of administration;

(iii) an administration of a dose or dosage to the wrong individual or human research subject;

(iv) an administration of a dose or dosage delivered by the wrong mode of treatment; or

(v) a leaking sealed source; and

(c) a dose to the skin or an organ or tissue other than the treatment site that exceeds by 50 rems (0.5 sievert) to an organ or tissue and fifty percent or more of the dose expected from the administration defined in the written directive (excluding, for permanent implants, seeds that were implanted in the correct site but migrated outside the treatment site).

(d) For permanent implant brachytherapy, the administration of byproduct material or radiation from byproduct material (excluding sources that were implanted in the correct site but migrated outside the treatment site) that results in-

(i) The total source strength administered differing by 20 percent or more from the total source strength documented in the post-implantation portion of the written directive;

(ii) The total source strength administered outside of the treatment site exceeding 20 percent of the total source strength documented in the post-implantation portion of the written directive; or

(iii) An administration that includes any of the following: the wrong radionuclide; the wrong individual or human research subject; sealed source(s) implanted directly into a location discontiguous from the treatment site, as documented in the post-implantation portion of the written directive; or a leaking sealed source resulting in a dose that exceeds 0.5 Sv (50 rem) to an organ or tissue.

(2) A licensee shall report any event resulting from intervention of a patient or human research subject in which the administration of radioactive material or radiation from radioactive material results or will result in unintended permanent functional damage to an organ or a physiological system, as determined by a physician.

(3) The licensee shall notify by telephone the department no later than the next calendar day after discovery of the medical event.

(4) The licensee shall submit a written report to the department within 15 days after discovery of the medical event.

(a) The written report must include:

(i) the licensee's name;

(ii) the name of the prescribing physician;

(iii) a brief description of the event;

(iv) why the event occurred;

(v) the effect, if any, on the individual(s) who received the administration;

(vi) what actions, if any, have been taken or are planned to prevent recurrence; and

(vii) certification that the licensee notified the individual (or the individual's responsible relative or guardian), and if not, why not.

(b) The report may not contain the individual's name or any other information that could lead to identification of the individual.

(5) The licensee shall provide notification of the event to the referring physician and also notify the individual who is the subject of the medical event no later than 24 hours after its discovery, unless the referring physician personally informs the licensee either that he or she will inform the individual or that, based on medical judgment, telling the individual would be harmful. The licensee is not required to notify the individual without first consulting the referring physician. If the referring physician or the affected individual cannot be reached within 24 hours, the licensee shall notify the individual as soon as possible thereafter. The licensee may not delay any appropriate medical care for the individual, including any necessary remedial care as a result of the medical event, because of any delay in notification. To meet the requirements of this paragraph, the notification of the individual who is the subject of the medical event may be made instead to that individual's responsible relative or guardian. If a verbal notification is made, the licensee shall inform the individual or appropriate responsible relative or guardian that a written description of the event can be obtained from the licensee upon request. The licensee shall provide such a written description if requested.

(6) Aside from the notification requirement, nothing in this section affects any rights or duties of licensees and physicians in relation to each other, to individuals affected by the medical event or to that individual's responsible relatives or guardians.

(7) A licensee shall:

(a) annotate a copy of the report provided to the department with the:

(i) name of the individual who is the subject of the event; and

(ii) social security number or other identification number, if one has been assigned, of the individual who is the subject of the event; and

(b) provide a copy of the annotated report to the referring physician, if other than the licensee, no later than 15 days after the discovery of the event.

B.Report and notification of a dose to an embryo, fetus or a nursing child.

(1) A licensee shall report any dose to an embryo or fetus that is greater than 5 rems (50 millisieverts) dose equivalent that is a result of an administration of radioactive material or radiation from radioactive material to a pregnant individual unless the dose to the embryo or fetus was specifically approved, in advance, by the authorized user.

(2) A licensee shall report any dose to a nursing child that is a result of an administration of radioactive material to a breast-feeding individual that:

(a) is greater than 5 rems (50 millisieverts) total effective dose equivalent; or

(b) has resulted in unintended permanent functional damage to an organ or a physiological system of the child, as determined by a physician.

(3) The licensee shall notify by telephone the department no later than the next calendar day after discovery of a dose to the embryo, fetus or nursing child that requires a report in Paragraphs (1) or (2) in this subsection.

(4) The licensee shall submit a written report to the department within 15 days after discovery of a dose to the embryo, fetus or nursing child that requires a report in Paragraphs (1) or (2) in this subsection.

(a) The written report must include:

(i) the licensee's name;

(ii) the name of the prescribing physician;

(iii) a brief description of the event;

(iv) why the event occurred;

(v) the effect, if any, on the embryo, fetus or the nursing child;

(vi) what actions, if any, have been taken or are planned to prevent recurrence; and

(vii) certification that the licensee notified the pregnant individual or mother (or the mother's or child's responsible relative or guardian), and if not, why not.

(b) The report must not contain the individual's or child's name or any other information that could lead to identification of the individual or child.

(5) The licensee shall provide notification of the event to the referring physician and also notify the pregnant individual or mother, both hereafter referred to as the mother, no later than 24 hours after discovery of an event that would require reporting under Paragraph (1) or (2) of this subsection, unless the referring physician personally informs the licensee either that he or she will inform the mother or that, based on medical judgment, telling the mother would be harmful. The licensee is not required to notify the mother without first consulting with the referring physician. If the referring physician or mother cannot be reached within 24 hours, the licensee shall make the appropriate notifications as soon as possible thereafter. The licensee may not delay any appropriate medical care for the embryo, fetus or for the nursing child, including any necessary remedial care as a result of the event, because of any delay in notification. To meet the requirements of this paragraph, the notification may be made to the mother's or child's responsible relative or guardian instead of the mother. If a verbal notification is made, the licensee shall inform the mother, or the mother's or child's responsible relative or guardian that a written description of the event can be obtained from the licensee upon request. The licensee shall provide such a written description if requested.

(6) A licensee shall:

(a) annotate a copy of the report provided to the NRC with the:

(i) name of the pregnant individual or the nursing child who is the subject of the event; and

(ii) social security number or other identification number, if one has been assigned, of the pregnant individual or the nursing child who is the subject of the event; and

(b) provide a copy of the annotated report to the referring physician, if other than the licensee, no later than 15 days after the discovery of the event.

C.Report of a leaking source. A licensee shall file a report within five days if a leak test required by Subsection F of 20.3.7.703 NMAC reveals the presence of 0.005 microcurie (185 becquerels) or more of removable contamination. The report must be filed with the department and it must include the model number and serial number, if assigned, of the leaking source, the radionuclide and its estimated activity, the results of the test, the date of the test and the action taken.

D.Report and notification for an eluate exceeding permissible molybdenum-99, strontium-82, and strontium-85 concentrations:

(1) The licensee shall notify by telephone the department and NRC Operations Center and the distributor of the generator within 7 calendar days after discovery that an eluate exceeded the permissible concentration listed in 10 CFR § 35.204(a) at the time of generator elution. The telephone report to the department and NRC must include the manufacturer, model number, and serial number (or lot number) of the generator; the results of the measurement; the date of the measurement; whether dosages were administered to patients or human research subjects, when the distributor was notified, and the action taken.

(2) By an appropriate method listed in 10 CFR § 30.6(a) of this chapter, the licensee shall submit a written report to the department and appropriate NRC Regional Office listed in 10 CFR § 30.6 of this chapter within 30 calendar days after discovery of an eluate exceeding the permissible concentration at the time of generator elution. The written report must include the action taken by the licensee; the patient dose assessment; the methodology used to make this dose assessment if the eluate was administered to patients or human research subjects; and the probable cause and an assessment of failure in the licensee's equipment, procedures or training that contributed to the excessive readings if an error occurred in the licensee's breakthrough determination; and the information in the telephone report as required by Paragraph (1) of this section.

N.M. Admin. Code § 20.3.7.716

20.3.7.716 NMAC - N, 4/30/2009, Amended by New Mexico Register, Volume XXXIV, Issue 03, February 14, 2023, eff. 2/14/2023