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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 53774 | 4 December 2018 05:00:00 | Agreement State | Agreement State Report - Occupational Exposure Exceeding Regulatory Limits | The following information was received from the State of Georgia via email: In accordance with Georgia Rule Chapter 391-3-17-.03-15(b)(3)(ii) (the licensee is notifying the Georgia Radioactive Material Program) of a potential extremity exposure exceeding regulatory limits to an occupational worker at Northside Hospital Atlanta. The timeline and circumstances are as follows: Northside Hospital received notification from Landauer ((the licensee's) personnel dosimetry vendor) on November 2, 2018, concerning an excessive reading of 58,748 millirem to an extremity dosimeter issued to (an employee) in Nuclear Medicine. (The licensee's) RSO immediately initiated an investigation which included a personal interview with the employee which resulted in the employee remembering the potential contamination of their ring dosimeter with a radiopharmaceutical as they were handling and injecting a patient dose during the period of use for that dosimeter; however, he was unsure as to the actual presence of contamination on the ring itself. The RSO assured the employee of the lack of any untoward effects but asked him for a follow-up for any skin effects that may have presented. Also it was noted that the whole body dosimeter during the same period showed only 25-30 millirem exposure. Based on this incident, there will be a renewed emphasis for all Nuclear Medicine Technologists that in the event of potential contamination to themselves and particularly to any personnel dosimeter, an immediate investigation by (the licensee's) RSO will be initiated and a report filed with (the licensee's) Radiation Safety Committee. | ||
| ENS 52341 | 21 October 2016 04:00:00 | Agreement State | Agreement State Report - Medical Misadministration to Incorrect Site | The following report was received from the State of Georgia via email: Northside Hospital's Radiation Safety Officer called the Department (Georgia Radioactive Materials Program Environmental Protection Division) on 10/21/2016, informing us of a misadministration with the HDR (High Dose Rate) that occurred approximately two weeks ago. The patient was to receive 5 vaginal treatments consisting of 1 cylinder, 1 capri and 3 capris. The misadministration occurred during the second treatment. The capri was inserted into the rectum instead of the vagina. The Authorized User (AU) was not certain if a misadministration occurred until 2 weeks after the treatment. The AU requested the assistance of the radiologist who confirmed that the rectum was treated instead of the vaginal area. Based on the calculations, the rectum received approximately 350 cGy, what is to be considered a low dose. Additional information from the licensee will be forthcoming. Treatment material used: Varian Medical Systems, model: Gamma Medplus iX, with an Ir-192 source of less than 22 Ci. A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient. |