# NRC ORDER – NOV (SL III)
> **EA-15-111** · ORDER · Severity SLIII · Issued 2015-08-27 · Materials Licensees
## Action
- **EA Number:** EA-15-111
- **Licensee:** NOV (SL III)
- **Category:** Materials Licensees
- **Action type:** ORDER
- **Severity level:** SLIII
- **Date issued:** 2015-08-27
## Description

On August 27, 2015, the NRC issued a Notice of Violation to McLaren Medical Center Bay Region for a Severity Level III violation involving the failure to develop, implement, and maintain written procedures to provide high confidence that each administration is in accordance with the written directive as required by 10 CFR 35.41(a). Specifically, as of February 6, 2015, the licensee failed to include specific steps in its procedure for verifying the catheter position in order to ensure the administration was in accordance with the written directive. As a result, a medical event occurred as the patient received an unintended dose of approximately 2.6 Gray (260 rad) to the skin of the right thigh.

## Source
- [Full enforcement letter (PDF)](https://www.nrc.gov/docs/ML1524/ML15240A222.pdf)
- [NRC Materials Licensees index](https://www.nrc.gov/reading-rm/doc-collections/enforcement/actions/materials/)
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