ENS 54334
ENS Event | |
|---|---|
04:00 Oct 15, 2019 | |
| Title | En Revision Imported Date 11/27/2019 |
| Event Description | EN Revision Text: CONTAMINATINON OF HOT LAB DUE TO BREAKING CAPSULE
The following report was received from the Georgia Radioactive Materials Program via email: A patient diagnosed with hyperthyroidism was scheduled to receive 30 mCi of Iodine-131 on Oct 15, 2019. The patient informed the AU [authorized user] that they could not swallow the capsule, so the AU proceeded to break the capsule in half and pour the contents in water to easily administer to the patient. The patient and AU were in the treatment room when the AU began to break the capsule. The AU then went to the hot lab where he successfully broke the capsule using a syringe needle. The nuclear technician inquired as to what was happening in the hot lab and realized that there may be a potential contamination issue and contacted the RSO [Radiation Safety Officer]. The areas were surveyed and determined to be contaminated with Iodine-131 was the hot lab, hallway in front of the hot lab, counter of the treatment room, scrub pants, shoes and socks. The RSO took the scrub pants and sock and shoes and placed them in an area for DIS [decay in storage]. He proceeded to clean the area from least contaminated, the hallway and treatment room, but could not get it completely clean. The treatment room is a less used room and isolated so that room could be sealed off and secured. The hallway is posted and cordon off. Currently, the RSO is uncertain as to how much contamination is in the hot lab and has the room sealed and secured until he can further assess the area. The staff who were working in the area consisted of the RSO, Assistant RSO, nuclear technician, and AU were monitored for thyroid uptake. Results were negative. The patient was not monitored for thyroid uptake since the patient was sitting at the opposite side of the treatment room opposite of where the contamination occurred. The floor of the room and adjacent hallway was free of contamination. In addition, the patient had a Iodine-123 uptake one week prior. So they would have had some residual Iodine-123 still in the body. The patient was never administered the Iodine-131 in water. The RSO will prepare a full report discussing the incident, root cause and correction plan within 15 days. An associate will be assigned to the event.
The following is a synopsis of a report received from the Georgia Radioactive Materials Program via email: On October 30, 2019 a reactive inspection was performed by the Georgia Radioactive Materials Program. The areas of contamination were verified to have a physical barrier to prevent inadvertent entry and signs posted to warn individuals of the contaminated areas. The Grady Memorial Hospital Radiation Safety officer (RSO) stated that the lab will not re-open until the contamination level reaches background, approximately 80 days from the time of the incident. The RSO temporarily removed the authorized user from administrating any therapeutic doses indefinitely. The RSO reported that there will be proper training for authorized users, technologists and residents who are involved in administering radioactive materials. A technologist will be required to be present in the room where I-131 is administered. Instructions will be added about not opening or breaking capsules containing radioactive materials to hospital procedures and refresher training will encompass the procedures. The physician did not think a bioassay was necessary for the patient as they were not exposed. Notified the R1DO (Henrion) and NMSS via email. |
| Where | |
|---|---|
| Grady Hospital Atlanta, Georgia (NRC Region 1) | |
| License number: | GA 258-2 |
| Organization: | Georgia Radioactive Material Pgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+37.33 h1.555 days <br />0.222 weeks <br />0.0511 months <br />) | |
| Opened: | Irene Bennett 17:20 Oct 16, 2019 |
| NRC Officer: | Jeff Herrera |
| Last Updated: | Nov 26, 2019 |
| 54334 - NRC Website | |
Grady Hospital with Agreement State | |
WEEKMONTHYEARENS 543342019-10-15T04:00:00015 October 2019 04:00:00
[Table view]Agreement State En Revision Imported Date 11/27/2019 2019-10-15T04:00:00 | |