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| Entered date | Event description | |
|---|---|---|
| ENS 40990 | 27 August 2004 09:35:00 | A misadministration occurred on August 5, 2004. The patient was an uncooperative 20 year old Down's Syndrome who was to be injected with 20 mCi of Tc-99m MDP for a bone scan. While attempting to restrain the patient the technologist mistakenly reached for and injected a 4.2 mCi DMSA renal scan dose. The patient was notified of the error and subsequently injected with the correct dose. The misadministration did not exceed the 5 rems effective dose equivalent or the 50 rems dose equivalent to any organ. The technologist was been counseled to obtain assistance when performing such administrations in the future. |
| ENS 40992 | 27 August 2004 11:09:00 | It has been determined that during a painting and insulation replacement: job on the exterior of the D-15 vessel at the Solvents Plant at Dow's Plaquemine manufacturing complex, a radiation shield was not locked out on a 500 mCi Cs-137 radiation source used for level detection. The zone of potential exposure was approximately 3 inches wide by 14 inches long on the external top of the tank. The work that was being performed was in such a manner that there could have been a possibility of hand or arm exposure. During the six day period it was determined that up to 16 persons had the potential to be exposed while completing the insulation replacement. A conservative estimate of 5 minutes total continuous exposure time over this period at a distance of 5 inches from the source yield a potential exposure of 421 mrems. A two minute total continuous exposure at a distance of 14 inches would yield a potential exposure of 31 mrems. The cause of the incident was failure to lock out a radiation shield prior to commencement of work. Lock out procedures for the facility have been reviewed and strengthened to prevent reoccurrence. Medical screening was performed on all potentially exposed personnel and the results were reviewed with the personnel. No effects were observed. |
| ENS 40991 | 27 August 2004 10:01:00 | On July 1, 2004 while Bayou Testers was performing quarterly inspections, they noticed that the case on a INC-100 industrial radiography camera was split open. The exposure devise was taken out of operation and sent to Source Production and Equipment (SPEC). The devise contained approximately 10 Ci of Ir-192. SPEC informed the licensee that the cause of the case splitting was corrosion of the depleted uranium shield, which caused it to swell and tear the weld. SPEC informed the licensee that this occurrence was not unusual. |