ENS 55639
ENS Event | |
|---|---|
19:04 Dec 1, 2021 | |
| Title | Deviation of Delivery Procedure by Common Carrier Staff Leaving Radioactive Material Unattended |
| Event Description | A Medical Oncology employee discovered a radioactive source package when exiting the Medical Oncology suite around 1420 EST on Wednesday, 12/1/2021. She noticed the label 'Radiation' and proceeded to pick it up and bring it into the Radiation Oncology suite down the hallway on the same floor (2nd floor) of the building. Radiation Oncology Staff notified Chief Therapist and Physicist who promptly brought the source into the designated area, performed a survey and inspection to ensure no break in seals or radiation leakage and to document the receipt of the package. [The source was a 10 Ci Ir-192 source. On contact readings with the package were 4.2 mR/hr and one meter survey reading was 0.6 mR/hr.] Later that evening, the regional Smilow radiation oncology physicist notified the hospital radiation safety officer who started an investigation on Thursday, 12/2/2021, morning.
[The common carrier's] tracking indicated that the package was delivered at 1404 EST on 12/1/2021, i.e., a few minutes prior to its discovery outside the Medical Oncology suite. The Medical Oncology secretary indicated that she had noticed a [common carrier] person in the hallway a few minutes prior to her finding the package outside the suite. The package was not delivered to the radiation therapy department at Greenwich Hospital as indicated by the shipper's declaration for dangerous goods and no signature/confirmation was obtained from the radiation therapy department for the delivery. Radiation exposure and potential risk to staff from this well shielded source over the incident encounter time would be negligible. The carrier has been notified of the incident, the fact that proper protocol was not followed in delivering the package and the fact that this is unacceptable. There was no measurable exposure to staff or patients. The incident is categorized as deviation from an already established and practiced radioactive material delivery procedure by [common carrier] staff. Radiation Oncology team had an in-service [training] to all concerned explaining this incident and as a reminder of procedures on delivery of radioactive material packages. We escalated this matter to the system [Yale New Haven Health System] (YNHHS) strategic resources who contacted the regional [common carrier] to obtain an explanation and corrective action from them. |
| Where | |
|---|---|
| Greenwich Hospital Greenwich, Connecticut (NRC Region 1) | |
| License number: | 06-09522-01 |
| Organization: | Greenwich Hospital |
| Reporting | |
| 10 CFR 20.2201(a)(1)(i) | |
| Time - Person (Reporting Time:+188.28 h7.845 days <br />1.121 weeks <br />0.258 months <br />) | |
| Opened: | Adel Mustafa 15:21 Dec 9, 2021 |
| NRC Officer: | Bethany Cecere |
| Last Updated: | Dec 10, 2021 |
| 55639 - NRC Website | |
Greenwich Hospital with 10 CFR 20.2201(a)(1)(i) | |
WEEKMONTHYEARENS 556392021-12-01T19:04:0001 December 2021 19:04:00
[Table view]10 CFR 20.2201(a)(1)(i) Deviation of Delivery Procedure by Common Carrier Staff Leaving Radioactive Material Unattended 2021-12-01T19:04:00 | |