Code of Massachusetts Regulations
105 CMR - DEPARTMENT OF PUBLIC HEALTH
Title 105 CMR 120.000 - The Control of Radiation
REPORTS
Section 120.594 - Reports and Notifications

Universal Citation: 105 CMR 120.000 MA Code of Regs 120.594

Current through Register 1531, September 27, 2024

(A) Report and Notification of a Medical Event.

(1) A licensee shall report any event as a medical event, except for an event that results from patient intervention, in which:
(a) The administration of byproduct material or radiation from byproduct material, except permanent implant brachytherapy, results in:
1. A dose that differs from the prescribed dose or dose that would have resulted from the prescribed dosage by more than 0.05 Sv (5 rem) effective dose equivalent, 0.5 Sv (50 rem) to an organ or tissue, or 0.5 Sv (50 rem) shallow dose equivalent to the skin; and
a. The total dose delivered differs from the prescribed dose by 20% or more;

b. The total dosage delivered differs from the prescribed dosage by 20% or more or falls outside the prescribed dosage range; or

c. The fractionated dose delivered differs from the prescribed dose for a single fraction, by 50% or more.

2. A dose that exceeds 0.05 Sv (5 rem) effective dose equivalent, 0.5 Sv (50 rem) to an organ or tissue, or 0.5 Sv (50 rem) shallow dose equivalent to the skin from any of the following:
a. An administration of a wrong radioactive drug containing byproduct material or the wrong radionuclide for a brachytherapy procedure;

b. An administration of a radioactive drug containing byproduct material by the wrong route of administration;

c. An administration of a dose or dosage to the wrong individual or human research subject;

d. An administration of a dose or dosage delivered by the wrong mode of treatment; or

e. A leaking sealed source.

3. A dose to the skin or an organ or tissue other than the treatment site that exceeds by:
a. 0.5 Sv (50 rem) or more the expected dose to that site from the procedure if the administration had been given in accordance with the written directive prepared or revised before administration; and

b. 50% or more the expected dose to that site from the procedure if the administration had been given in accordance with the written directive prepared or revised before administration.

(b) 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:
1. The total source strength administered differing by 20% or more from the total source strength documented in the post-implantation portion of the written directive;

2. The total source strength administered outside of the treatment site exceeding 20% of the total source strength documented in the post-implantation portion of the written directive; or

3. An administration that includes any of the following:
a. The wrong radionuclide;

b. The wrong individual or human research subject;

c. 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

d. 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 the Agency by telephone no later than the next calendar day after discovery of the medical event.

(4) The licensee shall submit a written report to the Agency within 15 days after discovery of the medical event.
(a) The written report must include:
1. The licensee's name;

2. The name of the prescribing physician;

3. A brief description of the event;

4. Why the event occurred;

5. The effect, if any, on the individual(s) who received the administration;

6. Actions, if any, that have been taken, or are planned, to prevent recurrence; and

7. 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 medical 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 105 CMR 120.594(A)(5), 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 105 CMR 120.594 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 retain a record of a medical event in accordance with 105 CMR 120.590(D). A copy of the record required under 105 CMR 120.590(D) shall be provided to the referring physician if other than the licensee, within 15 days after discovery of the medical 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/fetus that is greater than five mSv (500 mrem) 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/fetus was specifically approved, in advance, by the authorized user.

(2) A licensee shall report any dose to a nursing child, that was not specifically approved, in advance, by the authorized user, that is a result of an administration of radioactive material to a breast feeding individual that:
(a) Is greater than five mSv (500 mrem) 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 Agency no later than the next calendar day after discovery of a dose to the embryo/fetus or nursing child that requires a report in 105 CMR 120.594(B)(1) or 105 CMR 120.594(B)(2).

(4) The licensee shall submit a written report to the Agency within 15 days after discovery of a dose to the embryo/fetus or nursing child that requires a report in 105 CMR 120.594(B)(1) or 105 CMR 120.594(B)(2).
(a) The written report must include:
1. The licensee's name;

2. The name of the prescribing physician;

3. A brief description of the event;

4. Why the event occurred;

5. The effect on the embryo/fetus or the nursing child;

6. What actions, if any, have been taken, or are planned, to prevent recurrence; and

7. 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 notify the referring physician and also notify the pregnant individual or mother, both hereafter referred to as the mother, no later than 24 hours after of discovery of an event that would require reporting under 105 CMR 120.594(B)(1) or (2), 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, when appropriate. 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 retain a record of a dose to an embryo/fetus or a nursing child in accordance with 105 CMR 120.590(E). A copy of the record required under 105 CMR 120.590(E) shall be provided to the referring physician, if other than the licensee, within 15 days after discovery of the event.

(C) Reports of Leaking Sources. A licensee shall file a report with the Agency within five days if a leakage test required by 105 CMR 120.536 reveals the presence of 185 Becquerel (0.005 µCi) or more of removable contamination. The written report 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) Reports of Patient Departure Prior to Authorized Release.

(1) The licensee shall notify the Agency by telephone immediately upon discovery that a patient or human research subject has departed from the licensee's facility without authorization under 105 CMR 120.540(A).

(2) The licensee shall submit a written report to the Agency within 30 days after discovery of the unauthorized departure. The written report must include:
(a) The licensee's name;

(b) The date and time of the unauthorized departure;

(c) The projected date and time when release would have occurred;

(d) The general location address of the patient's or human research subject's home or anticipated destination following departure;

(e) The radionuclide, chemical and physical form and calculated activity at time of release;

(f) The apparent reason(s) for the departure prior to authorized release; and

(g) A description of any changes in the licensee's patient release criteria or patient instructions that are designed to avoid a recurrence of such an event.

(E) Notification of Deceased Patients or Human Research Subjects Containing Radioactive Material.

(1) The licensee shall notify the Agency by telephone immediately upon discovery that a patient or human research subject containing radioactive material has died, and it is possible that any individual could receive exposures in excess of 105 CMR 120.221 as a result of the deceased's body.

(2) The licensee shall submit a written report to the Agency within 30 days after discovery that the patient or human research subject referenced in 105 CMR 120.594(E)(1) has died. The written report must include:
(a) The licensee's name;

(b) The date of death;

(c) The radionuclide, chemical and physical form and calculated activity at time of death; and

(d) The names (or titles) and address(es) of known individuals who might have received exposures exceeding five mSv (500 mrem).

(F) Report and Notification for an Eluate Exceeding Permissible Molybdenum-99, Strontium-82, and Strontium-85 Concentrations.

(1) The licensee shall notify by telephone the Agency and the distributor of the generator within seven calendar days after discovery that an eluate exceeded the permissible concentration listed in 105 CMR 120.548(A) at the time of generator elution. The telephone report to the Agency 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 105 CMR 120.013, the licensee shall submit a written report to the Agency 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 105 CMR 120.594(F)(1).

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