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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 42086 | 26 October 2005 19:00:00 | Agreement State | Agreement State Report - Loose Surface Contamination and Contaminated Personnel | At 6:40 PM, October 26, 2005, the Agency's Duty Officer received a call from the dispatch center to contact Pharmacy Services of Peoria (IL-01874-01) at their Peoria facility regarding a contaminated package they had transported back from Proctor Hospital, Peoria, IL (IL-01188-01) earlier that afternoon. Pharmacy Services of Peoria reported that the package was contaminated on the surface with Tc-99m. Direct measurements yielded 3 milliR/hr and 4.9 million DPM. The package was immediately set aside in their waste area and secured. The driver was surveyed and contamination was found on one hand. His hand was decontaminated until readings were approximately 0.04 milliR/hr and no removable contamination remained. The pharmacy vehicle was subsequently surveyed and decontaminated to the extent practicable below releasable limits. Pharmacy Services of Peoria went on to state that he had contacted the hospital as well when the contamination was discovered that afternoon. The Duty Office then contacted, a technician of Proctor Hospital who indicated that a syringe of Tc-99m had partially vented which resulted in the contamination of her glove and the exterior of the retrieved pharmacy container. She stated that following notification from the pharmacy around 2 pm that afternoon, she had surveyed the hot lab for contamination and discovered loose radioactive contamination on the counter, the floor and the gloves she had been using at the time. She successfully decontaminated the floor and changed the counter absorbent covering. No other contamination had been found in the Department. On October 27, 2005 a Division representative called both individuals to follow-up and discuss reporting requirements. Pharmacy Services of Peoria advised that the courier had visited one other facility that afternoon following the collection of the briefcase containing empty lead containers at Proctor Hospital. Representatives from the pharmacy had called the second facility the previous afternoon to advise them of the potential for contamination. The second facility investigated and then reported back that their monitoring had revealed no contamination of the items dropped off. The pharmacy subsequently visited the site themselves later that same day to retrieve some empty containers and confirmed no contamination was present on any of the packages involved. He went on to report that the driver involved was monitored when he reported for work on the morning of the 27th and no additional removable contamination was discovered on his hands and as a further precaution the vehicle that had been used was set aside for the day and would not be driven. When the technician of Proctor Hospital was contacted she reported that she believed the contamination on the package resulted from a procedure where she was preparing a diagnostic tracer from a kit. Based on the initial amount involved and the subsequent diagnostic procedure she believed that no more than 0.5 milliCi of Tc-99m could have been involved. Circumstances in the hot lab and with available personnel lead to an uncommon situation where the package to be retrieved by the pharmacy courier was in the dose preparation area leading to its eventual contamination. Although routine procedure is to monitor all items removed from the radioactive work area of the hot lab, this was not performed on this occasion as it was unusual for the package to be in the dose preparation area. The licensee indicated that similar circumstances are very unlikely to be repeated so the potential for second occurrence is negligible. State Report: IL050052 |