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Event Notification Report for May 21, 2004

U.S. Nuclear Regulatory Commission
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Event Reports For
05/20/2004 - 05/21/2004

** EVENT NUMBERS **


40758 40759

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General Information or Other Event Number: 40758
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: MT. SINAI MEDICAL CENTER OF GREATER MIAMI, INC.
Region: 1
City: MIAMI BEACH State: FL
County: MIAMI-DADE
License #: 64-12
Agreement: Y
Docket:
NRC Notified By: CHARLES ADAMS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/18/2004
Notification Time: 16:31 [ET]
Event Date: 05/14/2004
Event Time: [EDT]
Last Update Date: 05/18/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JOHN CARUSO (R1)
CHARLES MILLER (NMSS)

Event Text

FLORIDA AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was received from the State of Florida Bureau of Radiation Control via e-mail:

"Patient was scheduled to receive a 2 fraction treatment to the breast over a five day period - for a total ten fractions. Prior to the last two fractions the doctor went out of town. The new doctor discovered that the calculated center of the balloon was off by 4 mm. The doctor chose to cancel the ninth & tenth fractions. Subsequent calculations showed the dose received was approximately 19 [to] 35% less than prescribed, depending on axis used relative to the catheter. The patient has been notified. This office was notified the day the last two fractions were canceled on May 14. However, review of events and the dose calculations were not complete until May 18. Licensee will send a written report on this event. Examination of this report will determine future Florida actions."

The fraction treatments were delivered using a Mammosite with an Ir-192, 6 Curie source. The maximum dose the patient received was calculated to be 2720 centiGray.

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Other Nuclear Material Event Number: 40759
Rep Org: CARDINAL HEALTH SYSTEMS
Licensee: RADIOPHARMACY OF BOISE
Region: 4
City: BOISE State: ID
County: ADA
License #: 11-27664-01MD
Agreement: N
Docket: 030-3536
NRC Notified By: WILLIE REGITS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/19/2004
Notification Time: 12:24 [ET]
Event Date: 05/18/2004
Event Time: 09:00 [MDT]
Last Update Date: 05/20/2004
Emergency Class: NON EMERGENCY
10 CFR Section:
30.50(b)(1) - UNPLANNED CONTAMINATION
Person (Organization):
TROY PRUETT (R4)
LINDA GERSEY (NMSS)

Event Text

UNPLANNED CONTAMINATION EVENT DUE TO SPILL OF IODINE-131

On 5/18/04 at 0900 hrs. MST, a radio pharmacist at Cardinal Health System's Radio pharmacy of Boise was preparing a vial of I-131 when the pig assembly failed and the pig and vial dropped to the floor, shattering the vial. Approximately 58 milliCuries of I-131 was spilled. The radio pharmacist was contaminated on his legs.

The licensee is currently collecting data to determine the skin dose to the pharmacist who decontaminated himself under the phone directions of the headquarters health physics technicians. Uptake data calculations are awaiting bioassay results. The pharmacist has been administered a dose of ThyroBlock as a precautionary measure.

The spill occurred in the restricted hot lab area. Decontamination of the lab area has removed all loose surface contamination. All fixed contamination has been shielded. Continuous air sampling is being used to determine volatility of the spilled material.

The licensee made a voice mail notification to R4DNMS (Katanic).

* * * UPDATE ON 05/20/04 AT 2011 EDT BY WILLIE REGITS TAKEN BY MACKINNON * * *

Preliminary findings based on initial surveys: Pharmacist region of contamination was limited to both knees and his left thumb. Max. exposed 10 square centimeters to knees was estimated to be 68 millirems. Estimated contamination to his left thumb was 6000 millirems. Two of the four individuals involved in the cleanup had elevated thyroid bioassays. One received 0.12 microcuries and the other received 0.04 microcuries.

In reference to event number 40760 reported by Saint Lukes Hospital: The spill at Cardinal Health Systems was thought to have contaminated two packages. The one shipped to Saint Lukes Hospital was found to be contaminated. The second package sent to another Hospital in Boise, Idaho was found not to be contaminated.

R4DO (Troy Pruett) and NMSS EO (Bob Pierson) notified of the update.

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