ENS 52928

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v t e ENS Event
20:15 Aug 24, 2017
Title	Agreement State Report - Contamination Resulting from Y-90 Setup
Event Description	The following was received from the State of Kansas via email: During Therasphere setup, a technician forgot to prime the syringe and inserted it into the vial of Y-90. She realized the syringe was not primed, but because the syringe cannot be removed, her attempt at priming it opened the vial inadvertently. It got tracked all over the room and to some extent all around the Interventional Radiology (IR) department. IR is now completely closed. She was put in a bunny suit immediately and sent to emergency to get deconned at the shower. There was no risk of internal contamination due to the rapidity of the decon after the incident. Highest contamination is at 90k on her scrubs. Most of the contamination was on her lead apron. The clothes are currently sequestered and lacking skin contamination, she was sent home. They are currently in the process of cleaning up and recovering to get IR back in business. An investigator will be sent on Monday to gain first-hand knowledge of the incident. The RSO and ARSO were at a conference, arriving home last night, and were not present during the incident. Reporting under 10 CFR 30.50(b) (corresponding to K.A.R. 28-35-184b in Kansas Annotated Regulations), area closed to workers and public for more than 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> due to an unplanned contamination.

ENS 52928 +/-
Where
University Of Kansas Hospital Kansas City, Kansas (NRC Region 4)
Organization:	Kansas Dept Of Health & Environment
Reporting

Agreement State
Time - Person (Reporting Time:+19.08 h0.795 days <br />0.114 weeks <br />0.0261 months <br />)
Opened:	James Uhlemeyer 15:20 Aug 25, 2017
NRC Officer:	Dong Park
Last Updated:	Aug 25, 2017
52928 - NRC Website
v • d • e

v t e Emergency Notification System
University Of Kansas Hospital with Agreement State
WEEKMONTHYEAR2017-08-24T20:15:00 [Table view]
[ENS list for University Of Kansas Hospital]

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