ENS 57696
ENS Event | |
|---|---|
04:00 May 5, 2025 | |
| Title | Potential Extremity Overexposure |
| Event Description | The following information was provided by the Pennsylvania Department of Radiation Protection (the Department) via email:
On May 6, 2025, and May 7, 2025, the licensee informed the Department of a possible high ring badge exposure of a nuclear medicine technologist. It is reportable per 10 CFR 20.2202(b)(1)(iii). On May 6, 2025, the licensee was notified by Mirion (their dosimetry provider) of a high ring badge exposure to a nuclear medicine technologist in the first quarter (Q1) of 2025. The exposure reading was 57,448 millirem, exceeding the allowable annual limit. The technologist also received a higher-than-normal dose to their whole-body badge of 405 millirem. The nuclear medicine technologist was notified about the exposure. The licensee interviewed the technologist to determine what may have caused the high reading on the ring badge. It was determined that the most likely source of the high reading was American College of Radiology phantom accreditation testing. The technologist performed the test twice in Q1 2025. The test involved injecting 15-25 mCi of Tc-99m into a water-filled phantom. The technologist does not recall injecting or handling the phantom without gloves on but thinks they must have handled the phantom without gloves and touched a small amount of contamination on the outside of the phantom. They also recall carrying the phantom from the hot lab to the camera and back, holding it to their body. This is believed to be the source of the higher-than-normal whole-body badge. The licensee believes that the nuclear medicine technologist may have handled the phantom without gloves on and picked up a small amount of contamination on their ring as a result. The Department will perform a reactive inspection. More information will be provided as received.
The following information was provided by the Pennsylvania Department of Radiation Protection (the Department) via email: Upon receiving the licensee's report and after being inspected for this event, the Department believes there is not a regulatory event to report. The corrective actions include the nuclear medicine technologist will always wear gloves when handling the phantom, injecting the Tc-99m into the phantom, and doing phantom testing. Also, the technologist will transport the phantom on a cart in the future. Information regarding this event will be shared with all technologists during annual training. Emphasis will be placed on always wearing gloves when handling phantoms and diligent hand or area monitoring upon completion of work. They will also stress the high concentrations of some radiopharmaceutical and quality control doses and how much Tc-99m can be present in a drop. They will also review the doses that can result from the presence of these amounts on the skin if not removed promptly. Pennsylvania Event Report ID: PA250007 Notified R1DO (Warnek) and NMSS Events Notification via email. |
| Where | |
|---|---|
| Allegheny Health Network Pittsburgh, Pennsylvania (NRC Region 1) | |
| License number: | PA-1659 |
| Organization: | Pa Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+59.13 h2.464 days <br />0.352 weeks <br />0.081 months <br />) | |
| Opened: | John Chippo 15:08 May 7, 2025 |
| NRC Officer: | Eric Simpson |
| Last Updated: | Jun 17, 2025 |
| 57696 - NRC Website | |
Allegheny Health Network with Agreement State | |
WEEKMONTHYEARENS 576962025-05-05T04:00:0005 May 2025 04:00:00
[Table view]Agreement State Potential Extremity Overexposure 2025-05-05T04:00:00 | |