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Event Notification Report for October 24, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
10/23/2019 - 10/24/2019

** EVENT NUMBERS **


54334

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Agreement State Event Number: 54334
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: GRADY HOSPITAL
Region: 1
City: ATLANTA   State: GA
County:
License #: GA 258-2
Agreement: Y
Docket:
NRC Notified By: IRENE BENNETT
HQ OPS Officer: JEFF HERRERA
Notification Date: 10/16/2019
Notification Time: 17:20 [ET]
Event Date: 10/15/2019
Event Time: 00:00 [EDT]
Last Update Date: 10/16/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DON JACKSON (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

CONTAMINATINON OF HOT LAB DUE TO BREAKING CAPSULE

The following report was received from the Georgia Radioactive Materials Program via email:

"A patient diagnosed with hyperthyroidism was scheduled to receive 30 mCi of Iodine-131 on Oct 15, 2019. The patient informed the AU [authorized user] that they could not swallow the capsule, so the AU proceeded to break the capsule in half and pour the contents in water to easily administer to the patient. The patient and AU were in the treatment room when the AU began to break the capsule. The AU then went to the hot lab where he successfully broke the capsule using a syringe needle. The nuclear technician inquired as to what was happening in the hot lab and realized that there may be a potential contamination issue and contacted the RSO [Radiation Safety Officer]. The areas were surveyed and determined to be contaminated with Iodine-131 was the hot lab, hallway in front of the hot lab, counter of the treatment room, scrub pants, shoes and socks.

"The RSO took the scrub pants and sock and shoes and placed them in an area for DIS [decay in storage]. He proceeded to clean the area from least contaminated, the hallway and treatment room, but could not get it completely clean. The treatment room is a less used room and isolated so that room could be sealed off and secured. The hallway is posted and cordon off. Currently, the RSO is uncertain as to how much contamination is in the hot lab and has the room sealed and secured until he can further assess the area.

"The staff who were working in the area consisted of the RSO, Assistant RSO, nuclear technician, and AU were monitored for thyroid uptake. Results were negative. The patient was not monitored for thyroid uptake since the patient was sitting at the opposite side of the treatment room opposite of where the contamination occurred. The floor of the room and adjacent hallway was free of contamination. In addition, the patient had a Iodine-123 uptake one week prior. So they would have had some residual Iodine-123 still in the body. The patient was never administered the Iodine-131 in water.

"The RSO will prepare a full report discussing the incident, root cause and correction plan within 15 days. An associate will be assigned to the event."


Page Last Reviewed/Updated Thursday, October 24, 2019
Thursday, October 24, 2019