ENS 50150
ENS Event | |
|---|---|
04:00 Jan 30, 2014 | |
| Title | Agreement State Report - Radiation Source Stored in Unapproved Location |
| Event Description | On January 30, 2014, two physicists within the Department of Radiation Oncology were emailed regarding the imminent shipment of a new Iridium-192 High Dose Rate (HDR) brachytherapy source. This notification was forwarded to the RSO. The source in its original shipping package was delivered by [the transport company] directly to the department on February 3, 2014. Upon arrival of the source, a front desk staff member tried unsuccessfully to notify two physics staff members while the transporter waited. When neither of physics staff members responded to the overhead page, front desk staff signed for the package at 9:43 a.m. The front desk staff member moved the package from the front desk area to the mold room floor (Room # 039.12), which is an unsecured location.
On February 14th, it was discovered that the source was not in the Radiation Oncology Hot Lab - the appropriate secured location. Upon investigation and questioning of the staff who signed for the package, the location of the source was determined at 2:15p.m. on February 14th. The source was then taken to the HDR suite by the HDR service engineer (on-site to perform the source exchange) before Radiation Safety personnel were able to perform a wipe test and survey the original shipping package. Upon arrival, Radiation Safety personnel performed a wipe test and survey of the inner shielding cask housing the source. ADDITIONAL INFORMATION ASSOCIATED WITH THE EVENT: -The source in its original shipping package was inappropriately stored in the mold room for approximately 11 days, 5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br />. -Only one female in the department has a declared pregnancy. At no point in time during this period (February 3rd- February 14th) did she enter the mold room. - The mold room is used only for the preparation of electron cutouts or blocks used in Linac-based treatments. This room is used infrequently (~5 visits per week - about 10 to 15 minutes per visit) by radiation oncology staff (physicists and dosimetrists) wearing radiation dosimeters. - Adjacent areas to the mold room are a clerical area on one side and hallways on the three other sides. - Exposure information obtained from the Radiation Safety personnel who surveyed the package on Friday, February 14th were 34 mR/hr at the surface and 0.5 mR/hr at 1 meter. - The timing of the wipe test and survey was not in accordance with the requirement that a package containing radioactive material be opened and inspected by the recipient as soon as possible (within 3 hours3.472222e-5 days <br />8.333333e-4 hours <br />4.960317e-6 weeks <br />1.1415e-6 months <br />) after receipt. - There was no notification directly from [the transport company] that the package was delivered. CAUSES OF FAILURE: -Procedure entitled 'Opening and Receiving of Radioactive Materials' was not followed. -Communication break-down between the front desk personnel and physics staff. ACTION TAKEN TO PREVENT RECURRENCE: 1. Establish one primary physicist and one back-up physicist to serve as the coordinator for the receipt of the radioactive package. Additional physicists within the department will be permitted access into the Radiation Oncology Hot Lab. Additionally, two physicists will sign off in the HDR source inventory logbook upon receipt of the source. 2. All physicists will be trained in accordance with departmental procedures and applicable Department of Transportation (DOT) regulations on the process of receiving this type of package into the department and ensuring its proper storage. 3. The shipping company will be contacted to add all physicists and Radiation Safety personnel to be notified that the source has been shipped. The shipping company will also provide a tracking number for every HDR source package shipped to this facility. Another notification will be made from the transport company that the source has arrived (including delivery confirmation, signature, time & date). 4. Training of all department personnel will be performed and documented. This training will include who is authorized to sign for a radioactive package, how to identify a radioactive package, and the process that should be followed to ensure a safe transfer of the package to Rhode Island Hospital custody. 5. The policy governing the receipt of this type of material will be reviewed, revised, and disseminated upon approval. 6. If the package has not been received within 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> of the shipping company's notification, the primary physicist will follow up with the shipping company to determine the location of the package. Rhode Island Event #2014-001 THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9) |
| Where | |
|---|---|
| Rhode Island Hospital Providence, Rhode Island (NRC Region 1) | |
| License number: | 7A-051-02 |
| Organization: | Ri Dept Of Radiological Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+2889.05 h120.377 days <br />17.197 weeks <br />3.957 months <br />) | |
| Opened: | Charma Waring 12:03 May 30, 2014 |
| NRC Officer: | Mark Abramovitz |
| Last Updated: | May 30, 2014 |
| 50150 - NRC Website | |
Rhode Island Hospital with Agreement State | |
WEEKMONTHYEARENS 555322019-04-17T16:00:00017 April 2019 16:00:00
[Table view]Agreement State Medical Event - Underdose of I-131 ENS 501502014-01-30T04:00:00030 January 2014 04:00:00 Agreement State Agreement State Report - Radiation Source Stored in Unapproved Location ENS 434782007-05-10T04:00:00010 May 2007 04:00:00 Agreement State Medical Afterloader-Applicator Placed in Incorrect Location ENS 419052005-07-18T04:00:00018 July 2005 04:00:00 Agreement State Agreement State Report - Medical Event 2019-04-17T16:00:00 | |