ENS 49206
ENS Event | |
|---|---|
06:59 Dec 1, 2010 | |
| Title | Agreement State Report - Badge Exposure Exceeding 5 Rem Annual Dose Limit |
| Event Description | The following was received from the State of Oregon via email:
Oregon Radiation Protection Services was notified by phone on January 19, 2011 at 1119 PDT, a representative of Good Samaritan Regional Medical Center, of a whole body (collar) badge report for the wear period of November 1-30, 2010 that exceeded the 5 rem dose limit. The monthly badge report was received by the licensee sometime after December 28, 2010 for an authorized user showing monthly/quarterly/annual dose as follows: Monthly (Nov 2010): SDE = 5032 mrem Quarterly (4Q2010): SDE = 5091 mrem Annual (2010) and Lifetime (hired in 2010): SDE = 5175 mrem The vendor (Landauer) performed a second read of the dosimeter that agreed with the reported doses above and stated that the imaging indicated an 'irregular exposure.' The authorized user stored his badge and ring in a 'cubby' along with his lab jacket. "On January 24th, the licensee emailed Oregon RPS with results from the licensee's investigation stating that the badge user was a student on rotation to the nuclear medicine dept. for the month of November. The user's previous WB badge results were 'normal' and no other nuclear medicine worker received a high dose reading during November. The student was '100% supervised' and is described as 'very conscientious about spills or drops.' Regardless, the licensee determined after eliminating several factors, that contamination was the most probably factor since the collar badge result was higher than the user's finger ring (4480 mrem SDE November, 5220 mrem SDE for 2010) and 'irregular exposure' noted by the dosimetry vendor. It remains unknown what isotope caused the overexposure and any Tc-99m has decayed to background. Surveys of the cubby and lab jacket were performed with negative results. In addition, the licensee stated that no 'large' iodine doses were administered for November. Remedial actions were not noted on the report. On July 16, 2013, a review was performed of this incident and it was discovered that it was not reported to the US NRC HOO as per the NRC's Reporting Material Events (SA-300), Appendix A. The specific requirement is 10 CFR 20.2203(a) which states, in part, that radiation doses that exceed the regulatory requirements (5 rem) are to be reported (30 day requirement). The licensee was e-mailed for any remedial actions taken after this event. On July 19, the licensee responded by e-mail stating that without a definitive cause for the overexposure, no change in procedure was instituted except heightened awareness of badge placement/location. The report was written and submitted via e-mail to the HOO on this same date. Oregon Radiation Protection Services noted on the Incident report that US NRC Operations Center was to be notified but this was not done." State Event Number: OR-11-0004 |
| Where | |
|---|---|
| Good Samaritan Regional Medical Center Corvallis, Oregon (NRC Region 4) | |
| License number: | Ore-90202 |
| Organization: | Or Dept Of Health Rad Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+23077.02 h961.543 days <br />137.363 weeks <br />31.611 months <br />) | |
| Opened: | Daryl A. Leon 19:00 Jul 19, 2013 |
| NRC Officer: | Daniel Mills |
| Last Updated: | Jul 19, 2013 |
| 49206 - NRC Website | |
Good Samaritan Regional Medical Center with Agreement State | |
WEEKMONTHYEARENS 492972013-08-21T20:45:00021 August 2013 20:45:00
[Table view]Agreement State Agreement State Report - Patient Given Dose Prescribed for Another Patient ENS 492062010-12-01T06:59:0001 December 2010 06:59:00 Agreement State Agreement State Report - Badge Exposure Exceeding 5 Rem Annual Dose Limit 2013-08-21T20:45:00 | |