ENS 53482
ENS Event | |
|---|---|
05:00 Jan 15, 2016 | |
| Title | Agreement State Report - Unplanned Contamination |
| Event Description | The following information was received from the State of Kansas via email:
The licensee had an incident with an I-131 patient that resulted in the Iodine Patient room being badly contaminated along with the patient's bed and some other room furniture. The room is secured and removed from service. When the licensee has their Weekday management staff meeting on Monday, they develop a plan to complete the room decontamination and return it to service. The room is removed from clinical service at 2100 today (15 Jan 16). The contamination is contained within the room and there is no risk to Hospital staff or members of the public. No unintended dose to the patient, staff or other personnel. The patient was on a Foley catheter with the urine bag in a roll able pig. She got out of bed and walked around the room and "dragged" the pig. The hose connection inside the pig was damaged and urine spilled inside the pig and some was spilled on the floor. No one was contaminated - skin or clothing ... just the floor. The easily removable contamination / urine is cleaned up and will leave the room to decay for a half-life. That will make clean-up easier and also will reduce dose to those who are involved in the detailed cleanup. The licensee will notify the department when the room is returned to service. 6/28/2018 - Patient administered 159.8 milliCuries Iodine-131 on 1/13/2016. The patient placed on a catheter because they were incontinent, had early Alzheimer's, and was not able to comply with instruction. The patient catheter with urine bag was placed in a 'rollable pig' which was dragged around the room when the patient walked around the room. The hose connection was damaged about the second day and urine spilled in the pig and onto the floor covering, bedding, linens, and absorbent chucks. The patient was released with an estimated 28 milliCuries Iodine-131 remaining on 1/15/2016. The initial room survey indicated high contamination levels. The decision was made to allow the contamination to decay over the weekend to allow for lower exposure to personnel performing the decontamination, and determine the contamination levels, location and a plan to decontaminate the room. The contamination was determined to be confined to the bed (mattress), linens, absorbent chucks and plastic sheeting. Minor contamination was found on the floor under the plastic sheeting. The contaminated items were removed from the room and held for 10 half-lives decay. The floor was surveyed and contaminated spots were decontaminated. The room was returned to clinical service Monday morning 1/18/2016. The time out of service was approximately 60 hours6.944444e-4 days <br />0.0167 hours <br />9.920635e-5 weeks <br />2.283e-5 months <br />. 6/29/2018 - Integrated Material Performance Evaluation Program (IMPEP) review identified the event had not been reported to the NRC as required. Kansas Item Number: KS160001 |
| Where | |
|---|---|
| Via Christi Regional Medical Center Wichita, Kansas (NRC Region 4) | |
| License number: | 18-C753-01 |
| Organization: | Kansas Dept Of Health & Environment |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+21583.45 h899.31 days <br />128.473 weeks <br />29.565 months <br />) | |
| Opened: | James Harris 11:27 Jul 2, 2018 |
| NRC Officer: | Bethany Cecere |
| Last Updated: | Jul 2, 2018 |
| 53482 - NRC Website | |
Via Christi Regional Medical Center with Agreement State | |
WEEKMONTHYEARENS 534822016-01-15T05:00:00015 January 2016 05:00:00
[Table view]Agreement State Agreement State Report - Unplanned Contamination 2016-01-15T05:00:00 | |