ENS Event | |
|---|---|
04:00 Jul 24, 2025 | |
| Title | Potential Over Exposure |
| Event Description | The following report was received by the Georgia Radioactive Materials Program via email:
The licensee's radiation safety officer called and stated that, during a high dose rate procedure, the nurse got stuck in the vault and was behind the CT [computed tomography] lead shielding. The licensee plans to send out her dosimetry badge to be processed for dose received and perform a pregnancy test. [The Georgia Radioactive Materials Program] will follow up with more information as we receive it. Additional information: The equipment involved was a GammaMedPlus 3/24iX remote brachytherapy afterloader containing a Ir-192 source with an activity of 3.158 curies.
The following report was received by the Georgia Radioactive Materials Program via email: The licensee sent in the final report along with the dosimetry for the nurse involved in the incident. The nurse was in an adjacent procedure room that connects to the HDR [high dose rate] vault. It is used for gynecologic preparation and is shielded for CT [computed tomography] energy, but not Ir-192. The nurse was restocking the room and did not realize the treatment had started. The procedure was interrupted by the team upon hearing [the nurse] call out. [The nurse] was in the room 10 out of the 11 minutes. [The nurse] estimated unshielded dose was 12 mRem. The nurse's TLD [thermoluminescent dosimeter] badge read minimum exposure after the incident. The licensee is updating their procedures and check list to include checking all adjacent rooms before beginning the procedure. They will be retraining the staff on HDR safety procedures and plan to evaluate an audible alarm to accompany the beam on lights for the vault. This has been determined not to be a reportable event. Notified R1DO (Bickett) and NMSS Events (email) Georgia Incident Number: 104 |
| Where | |
|---|---|
| Tanner Health System Carrollton, Georgia (NRC Region 1) | |
| License number: | GA 120-2 |
| Organization: | Georgia Radioactive Material Pgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+12.37 h0.515 days <br />0.0736 weeks <br />0.0169 months <br />) | |
| Opened: | Jake Chesser 16:22 Jul 24, 2025 |
| NRC Officer: | Ernest West |
| Last Updated: | Aug 11, 2025 |
| 57826 - NRC Website | |
Tanner Health System with Agreement State | |
WEEKMONTHYEARENS 579802025-10-10T04:00:00010 October 2025 04:00:00
[Table view]Agreement State Lost Calibration Source ENS 578262025-07-24T04:00:00024 July 2025 04:00:00 Agreement State Potential Over Exposure 2025-07-24T04:00:00 | |