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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 53461 | 19 June 2018 04:00:00 | Agreement State | Agreement State Report - Removable Contamination on Package | The following information was received via E-mail: North Carolina Radioactive Material Branch (NCRMB) is reporting the following event: On 6/19/2018, Memorial Mission Hospital, Asheville (NC License, 0091-6) reported receiving two Biodex PET boxes containing F-18 FDG (fludeoxyglucose) from Cardinal Health, Asheville (NC License, 0794-7). Both boxes were delivered to Cardinal Health, Asheville via courier from Cardinal Health, Charlotte (NC License, 0794-1). Upon receipt of the boxes, Memorial Mission personnel performed surveys and wipes and noted the following contamination for Tc-99m on the boxes with the concentration of contamination being on the side handles of both boxes: Box 1: 88.96 kdpm/300 cm2 Box 2: 46.92 kdpm/300 cm2 No contamination was found inside either of the boxes containing F-18 patient doses and contamination was only on outside handles of both boxes. Memorial Mission confirmed that no further contaminated packages were received. Cardinal Health, Charlotte performed wipes and surveys of its work areas, courier vehicle and personnel. No contamination was found at this location with regards to this event. Cardinal Health, Asheville performed wipes and surveys of its work areas, courier vehicle and personnel. The courier at this location that delivered the two boxes to Memorial Mission Hospital is also a Pharmacy Technician. Removable contamination was found on this person's hands and cleaned. No other contamination was discovered at this location or the courier vehicle. No other notifications were made to any other agencies in NC. NCRMB was notified same day as the event. There are no other generic implications. NCRMB has dispatched an inspector to perform an on-site investigation. This report will be updated once more information is discovered, to include corrective actions and any other info needed to close and complete this report. Reporting Requirement: 10 CFR 20.1906(d)(1): Reports of removable contamination on package > limits in 10 CFR 71.87; removable contamination greater than limits specified in 49 CFR 173.443. NC Tracking Event Number: 180028. | ||
| ENS 43321 | 24 April 2007 04:00:00 | Agreement State | Agreement State Report - North Carolina - Misadministration of Iodine-131 | The State provided the following information via facsimile: The State of North Carolina was notified on 4/26/07 of a misadministration of diagnostic Iodine-131. The event involved a "misdrawn and mislabeled dose from Shertech Pharmacy in Ashville NC (NC licensee 011-1203-1). The written directive (from the hospital) was for 30 microcuries for a diagnostic thyroid scan but 33.9 millicuries was delivered labeled as 33.9 microcuries. Nuclear Medical Technologist at Memorial Mission missed the error because they read the numbers (33.9) but not the units (millicuries vs. microcuries). Dose was administered on 4/24/07 and the error was found on 4/26/07. Patient and physician notified. Licensee is following up with Shertech." No information is available on any potential medical impact of the misadministration on the patient. 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. |