ENS 54373

v t e ENS Event
07:00 Nov 1, 2019
Title	Agreement State Report - Contamination Due to Dislodged Catheter
Event Description	The following was received from the Colorado Radioactive Materials Unit via email: On 11/6/19, the Colorado Department of Public Health and Environment was notified of a potential reportable contamination event. On 11/1/19, approximately 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> after an I-131 MIBG [meta-iodobenzylguanidine] administration (293.6 mCi) on 10/31/19, the patient's catheter was dislodged [while asleep]. I-131 contaminated urine spilled out of the catheter and contaminated the patient, bed, bedding, and floor under the bed. Most of the spill was located under the bed. The patient was decontaminated after the spill was identified and has since been released from the facility. After the patient was released, the extent of the spill was identified by the licensee. The treatment room has not been released for unrestricted use as of 11/6/19. Dose rates taken by the licensee indicate the potential for greater than 5 times the ALI [annual limit on intake] prior to decontamination efforts. Colorado Event Report No: CO190018 A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

ENS 54373 +/-
Where
Children'S Hospital Colorado Aurora, Colorado (NRC Region 4)
License number:	CO 075-02
Organization:	Colorado Dept Of Health
Reporting

Agreement State
Time - Person (Reporting Time:+128.57 h5.357 days <br />0.765 weeks <br />0.176 months <br />)
Opened:	Phillip Peterson 16:34 Nov 6, 2019
NRC Officer:	Ossy Font
Last Updated:	Nov 6, 2019
54373 - NRC Website
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Children'S Hospital Colorado with Agreement State
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