Event Notification Report for September 28, 2021

EN Revision Imported Date: 9/28/2021

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

The following information was received from NMED for the Georgia Radioactive Materials Program:

"This incident occurred on July 14 at Piedmont Fayette Hospital (GA 1340-1). The unnecessary study was an administration of 25.6 mCi of Tc-99m exametazime-labeled white blood cells (Ceretec WBC), for which the TEDE was about 9 mSv. The individual who received the unnecessary study only came to the hospital for the study and was not an inpatient or there for any other reason."

Georgia Incident Number: 45

* * * UPDATE FROM JOHN HAYS TO THOM HERRITY AT 1142 EDT ON 09/27/21 * * *

The following is a synopsis of the root cause conducted by the Piedmont Fayette Hospital:

The order for the study was received by the imaging center on June 2, 2021. However, the order date for the study was December 16, 2015. The reason for this discrepancy was due to a training mishap at the ordering doctor's office. Staff at the imaging center did not observe the date discrepancy between the fax date at the top of the page and the order date in smaller print elsewhere in the document. The individual receiving the dose had not seen the ordering physician since 2015. At the time the order was received, the individual receiving the dose was under the care of a different physician than the ordering physician and the individual receiving the dose assumed that the different physician had ordered the study.

The hospital Radiation Safety Officer (RSO) has concluded that, because the individual was not actually a patient, the exposure should be reclassified as an exposure to a member of the public, which has lower reporting limits than a misadministration. The TEDE was approximately 8.5 mSv (0.85 rem). No ill effects are anticipated from this exposure. The hospital has initiated re-training for staff to preclude similar confusion going forward.

Notified R1DO (SCHROEDER) and NMSS Events Notification group.

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.

EN Revision Imported Date: 9/28/2021

EN Revision Text: AGREEMENT STATE REPORT - LOSS OF CONTROL OF RADIOACTIVE MATERIAL

The following report was received from the Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (the Division) via email:

"On August 27, 2021, local heavy rain infiltrated the Merrill Engineering Building, causing flooding on the first and third floors. The first floor also included some radioactive materials labs. While stripping the labs on September 9, 2021, in preparation for repair, the contractor violated policy and failed to notify the lab owners before moving material from the lab. Included in the material removed from the lab was a safe containing 13 exempt calibration sources and one 0.006 milliCurie U-235 ceramic source. The safe was moved to an onsite trailer that was under control of the contractor and not the University. When the lab owner returned to the lab later in the day they immediately reported the sources missing. Investigation by licensee personnel lead them to where the sources were being stored. The sources were out of the licensee's exclusive control for 1 to 3 hours. The sources were re-secured and placed under the licensee's exclusive control closing the incident. The report was not determined to be reportable until the Division was able to conduct its on site investigation on September 20, 2021."

Utah Event Report ID Number: UT 210005

THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf