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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 46349 | 20 October 2010 14:30:00 | 10 CFR 20.1906(d)(1) | Loose Surface Contamination Found on Outside of Radiopharmaceutical Packaging | The package was received today (October 20, 2010) at about 10:00 AM EDT by the VA Maryland Healthcare System, Baltimore, Maryland. A wipe test performed on the external surface of the package indicated a removable contamination level of about 1800 dpm/cm2 as compared to the regulatory limit of 220 dpm/cm2 for beta-gamma emitters. The package contained a unit dosage of around 12 milliCuries of Fluorine-18 labeled radiopharmaceuticals and was shipped from Cardinal Health, Baltimore, Maryland. The vendor/shipper also serves as the delivery carrier. The VA nuclear medicine staff immediately notified staff at Cardinal Health about the contaminated package around 10:30 AM EDT. As corrective actions, additional wipe samples were taken in the VA nuclear medicine department, and the indication was that the package was most likely inadvertently cross-contaminated by a technologist who had handled similar materials just before checking in the package. Specifically, a contaminated absorbant pad was identified near the check-in area. The healthcare system Radiation Safety Officer (RSO) indicated that additional area and personnel surveys were performed to ensure that residual contamination in the area was identified and addressed appropriately. Also, the RSO reinstructed the technologists involved in the incident on proper material handling techniques to avoid future cross-contamination of items and packages. Additional reinstruction of technologists is planned. As additional follow-up information, the RSO spoke to the pharmacy supervisor at Cardinal Health around 12:00 PM EDT and again at 1:30 PM EDT and learned that the driver and the vehicle were surveyed by the vendor and found to be free of contamination. Also, the vendor received no other reports of contaminated packages from other customers. This information supports a conclusion that the contamination was most likely from cross-contamination after package receipt. We will notify our NRC Project Manager at NRC Region III of this event. |