# NRC CAL – NOV (SL III)
> **EA-10-141** · CAL · Severity SLIII · Issued 2010-08-24 · Materials Licensees
## Action
- **EA Number:** EA-10-141
- **Licensee:** NOV (SL III)
- **Category:** Materials Licensees
- **Action type:** CAL
- **Severity level:** SLIII
- **Date issued:** 2010-08-24
## Description

On August 24, 2010, the NRC issued a Notice of Violation to the Christiana Care Health Services (CCHS), for a Severity Level III violation involving the failure to develop and maintain written procedures to provide high confidence that each administration requiring a written directive was performed in accordance with the written directive as required by 10 CFR 35.41. Specifically, CCHS's written procedures for high dose rate remote afterloader (HDR) treatments did not: (i) include a quality assurance process to test and evaluate proper functioning of all measurement tools used to determine treatment parameters; and, (ii) specify how personnel should respond when unknown and questionable treatment distances were encountered during HDR simulation measurements. As a result of these procedural inadequacies, a medical event occurred, in which the patient received a dose to unintended tissue and did not receive the prescribed dose to the intended tissue during an HDR treatment conducted between January 18 and January 22, 2010.

## Source
- [Full enforcement letter (PDF)](https://www.nrc.gov/docs/ML1023/ML102370150.pdf)
- [NRC Materials Licensees index](https://www.nrc.gov/reading-rm/doc-collections/enforcement/actions/materials/)
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