OAR 333-116-0125: Quality Management Program

(1) Each applicant or licensee under this division, as applicable, must establish and maintain a written quality management program to provide high confidence that radioactive material or radiation from radioactive material will be administered as directed by the authorized user. The quality management program must include written policies and procedures to meet the following specific objectives: (a) That, prior to administration, a written directive (see NOTE below) is prepared for: (A) Any teletherapy radiation dose; (B) Any gamma stereotactic radiosurgery radiation dose; (C) Any brachytherapy radiation dose; (D) Any administration of quantities greater than 1.11 megabecquerels (30 uCi) of either sodium iodide I-125 or I-131; or (E) Any therapeutic administration of a radiopharmaceutical, other than sodium iodide I-125 or I-131; (b) That, prior to each administration, the patient's identity is verified by more than one method as the individual named in the written directive; (c) That final plans of treatment and related calculations for brachytherapy, teletherapy, and gamma stereotactic radiosurgery are in accordance with the respective written directives; (d) That each administration is in accordance with the written directive; and (e) That any unintended deviation from the written directive is identified and evaluated, and appropriate action is taken. NOTE: If, because of the patient's condition, a delay in order to provide a written revision to an existing written directive would jeopardize the patient's health, an oral revision to an existing written directive will be acceptable, provided that the oral revision is documented immediately in the patient's record and a revised written directive is signed by the authorized user within 48 hours of the oral revision. Also, a written revision to an existing written directive may be made for any diagnostic or therapeutic procedure provided that the revision is dated and signed by an authorized user prior to the administration of the radiopharmaceutical dosage, the brachytherapy dose, the gamma stereotactic radiosurgery dose, the teletherapy dose, or the next teletherapy fractional dose. If, because of the emergent nature of the patient's condition, a delay in order to provide a written directive would jeopardize the patient's health, an oral directive will be acceptable, provided that the information contained in the oral directive is documented immediately in the patient's record and a written directive is prepared within 24 hours of the oral directive. (2) The licensee shall: (a) Develop procedures for and conduct a review at least every 12 months of the quality management program that includes an evaluation of: (A) A representative sample of patient administrations; and (B) All medical events as defined in OAR 333-116-1000 to verify compliance with all aspects of the quality management program; (b) Evaluate each of the quality management program reviews to determine the effectiveness of the quality management program and, if required, make modifications to meet the objectives of subsection (2)(a) of this rule; and (c) Retain records of each review, including the evaluations and findings of the review, in an auditable form for three years. (3) The licensee shall evaluate and respond, within 30 days after discovery of a medical event by: (a) Assembling the relevant facts including the cause; (b) Identifying what, if any, corrective action is required to prevent recurrence; and (c) Retaining a record, in an auditable form, for five years or until inspected by the Authority whichever is greater, of the relevant facts and what corrective action, if any, was taken. (4) The licensee shall retain: (a) Each written directive; and (b) A record of each administered radiation dose or radiopharmaceutical dosage where a written directive is required in subsection (1)(a) of this rule, in an auditable form, for five years, or until inspected by the Authority whichever is greater, after the date of administration. (5) The licensee may make modifications to the quality management program to increase the program's efficiency provided the program's effectiveness is not decreased. The licensee shall furnish the modification to the Authority within 30 days after the modification has been made. (6) Each applicant for a new license, as applicable, shall submit to the Authority in accordance with OAR 333-102-0190 a quality management program as part of the application for a license and implement the program upon issuance of the license by the Authority.