795 / 1224
“The NRC has received reports of numerous medical events caused by
errors in confusing the units of source strength in the specification of
sources—specifically, units of air-kerma strength and apparent activity in
units of millicurie (mCi).”
“human error caused all these events”
27% overdose errors with
125
I
78% overdose errors with
192
Ir
use of apparent activity for brachytherapy sources is
unsafe and inexcusable
NRC Information Notice 2009-17