ENS 48033
ENS Event | |
|---|---|
08:30 Jun 15, 2012 | |
| Title | Agreement State Report - Burst Vial of Tc99M in Nuclear Pharmacy |
| Event Description | The following information was received via email:
On Friday, June 15, 2012, at approximately 0230 Mountain Daylight Time (MDT), a nuclear pharmacy licensee located in Grand Junction, Colorado, had a vial containing approximately 1.9 Ci of liquid Tc99m burst and likely volatilize following placement on a heating block as part of compounding activities for preparation of cardiac imaging (Sestamibi) radiopharmaceuticals. The pharmacist, who also serves as the Radiation Safety Officer (RSO), notified the Colorado Department of Public Health and Environment (CDPHE) Radioactive Materials Unit on-call duty officer several hours later at approximately 1000 MDT on Friday, June 15. Following the initial notification to CDPHE, a secondary phone interview of the pharmacist was conducted. It was determined that the burst container resulted in contamination of the pharmacist, compounding area (generator room), and areas within the main pharmacy. The pharmacist was the only person in the facility at the time of the incident. Other staff - primarily courier personnel - arrived after the incident, and provided some assistance but reportedly did not enter the pharmacy lab area. As a result of the ruptured vial, radiation survey instruments in the laboratory became contaminated, which required the licensee to borrow instrumentation from a local hospital licensee. Sometime following the incident, the pharmacist initiated limited decontamination activities of himself (glove and lab coat removal/exchange) and the area. The pharmacist reportedly continued with the preparation of some radiopharmaceutical materials following the incident. Additionally, following gross decontamination activities at the pharmacy, the pharmacist left the licensee facility to shower and change clothing at his residence. During phone interviews with the licensee, CDPHE requested that the pharmacist obtain a urine sample, prepare for the return and processing of personal dosimeter badges and arrange for a back-up pharmacist. The pharmacist was directed to not conduct work involving radioactive material, pending further evaluation of internal and external dose. In response to the incident, CDPHE dispatched the on-call duty officer from the Denver office to the Grand Junction area on Friday afternoon. (NOTE - Grand Junction, Colorado is approximately 5.5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br /> drive time from the Denver CDPHE office). CDPHE staff met with the licensee pharmacist/RSO on the morning of Saturday, June 16, 2012 to evaluate the situation and perform surveys of potentially impacted areas and personnel. A whole body scan of the pharmacist was conducted at a local hospital nuclear medicine department in the later morning of Saturday, June 16. Personnel surveys of the pharmacist and the scan did not indicate the presence of radioactive material. Further details and information are being gathered. No members of the public were believed to have been exposed above public dose limits as a result of the incident, and radioactive materials are believed to be contained within the lab area, with the exception of minor contamination discovered near the back door to the pharmacy. The Department continues to investigate the incident and is gathering additional information." THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source |
| Where | |
|---|---|
| Nuquest, Inc. Grand Junction, Colorado (NRC Region 4) | |
| License number: | 1022-01 |
| Organization: | Colorado Dept Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+77.47 h3.228 days <br />0.461 weeks <br />0.106 months <br />) | |
| Opened: | James Jarvis 13:58 Jun 18, 2012 |
| NRC Officer: | Donald Norwood |
| Last Updated: | Jun 18, 2012 |
| 48033 - NRC Website | |
Nuquest, Inc. with Agreement State | |
WEEKMONTHYEARENS 480332012-06-15T08:30:00015 June 2012 08:30:00
[Table view]Agreement State Agreement State Report - Burst Vial of Tc99M in Nuclear Pharmacy 2012-06-15T08:30:00 | |