ENS 51774: Difference between revisions

v t e ENS Event
05:00 Mar 2, 2016
Title	Agreement State Report - Contamination Event with Possible Shallow Dose Exceeding Federal Limits
Event Description	The following report was received from the Commonwealth of Pennsylvania via facsimile: Notifications: The event occurred on March 2, 2016, the licensee discovered the event on March 3, 2016, and notified the Department [Pennsylvania Department of Environmental Protection] on March 4, 2016, via a phone call. The event is reportable per 10 CFR 30.50(b)(1)(i) and 10 CFR 20.2202(b)(1)(iii). Event Description: On March 2, 2016, a technologist was injecting a samarium-153 'Quadramet' dose (approximately 81 milliCuries) when there was a problem with the syringe/tubing connection. A 'blowback' occurred and a small amount, believed to be approximately 1-2 mCi, of the dose spilled. The patient was released [and sent] home. The technologist stated that he had gloves on, washed his hands, surveyed the area and called the lead technologist to notify her of the incident. Radiation Safety [at the hospital] was not notified until March 3rd. The technologist was surveyed and found to have contamination on his hands and forearms. An initial calculation indicated a skin dose above 50 rem. Radiation Safety then took smears throughout the department and contamination was found on various surfaces including the floor, other technologist's hands, gloves, shoes, survey meters, chairs, and clothing. Removable contamination was also found in a technologist's vehicle. Radiation Safety has decontaminated most areas. Surfaces and rooms that were not able to be decontaminated were closed off (for decay) or covered with paper to prevent any further spread of contamination. It is believed that after the spill, the technologist attempted to clean up the area. Apparently it was not sufficient, for when housekeeping did their routine cleaning, they may have unknowingly further spread the contamination with floor mopping and other cleaning. No biological effects are expected with any individual. The RSO [Radiation Safety Officer] feels that a 'medical event' did not occur with the patient. The patient returned for a scheduled scan on March 3rd, and that scan appeared normal. The patient did not show any signs of detectable contamination on her skin. Cause of the Event: Human error. The technologist may not have followed proper procedures, and contributed to the contamination spreading beyond initial spill area. Actions: A reactive inspection is planned by the Department [Pennsylvania Department of Environmental Protection]. More information will be provided upon receipt. Event Report ID No: PA160008

ENS 51774 +/-
Where
Allegheny General Hospital Pittsburgh, Pennsylvania (NRC Region 1)
License number:	PA-0031
Organization:	Pa Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+129.93 h5.414 days <br />0.773 weeks <br />0.178 months <br />)
Opened:	Joesph Melnic 14:56 Mar 7, 2016
NRC Officer:	John Shoemaker
Last Updated:	Mar 7, 2016
51774 - NRC Website
v • d • e

v t e Emergency Notification System
Allegheny General Hospital with Agreement State
WEEKMONTHYEAR2016-03-02T05:00:00 [Table view]
[ENS list for Allegheny General Hospital]

@@ Line 3: / Line 3: @@
 | facility = Allegheny General Hospital
 | Organization = Pa Bureau Of Radiation Protection
-| license number = Pa-0031
+| license number = PA-0031
 | region = 1
 | state = Pennsylvania

ENS 51774: Difference between revisions

Latest revision as of 19:03, 24 November 2018

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ENS 51774: Difference between revisions

Latest revision as of 19:03, 24 November 2018

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