Event Notification Report for June 20, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/19/2022 - 06/20/2022
EVENT NUMBERS
55961
55961
Agreement State
Event Number: 55961
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Decatur Memorial Hospital
Region: 3
City: Decatur State: IL
County:
License #: IL-02444-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Ossy Font
Licensee: Decatur Memorial Hospital
Region: 3
City: Decatur State: IL
County:
License #: IL-02444-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Ossy Font
Notification Date: 06/24/2022
Notification Time: 14:51 [ET]
Event Date: 06/20/2022
Event Time: 00:00 [CDT]
Last Update Date: 07/05/2022
Notification Time: 14:51 [ET]
Event Date: 06/20/2022
Event Time: 00:00 [CDT]
Last Update Date: 07/05/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Dickson, Billy (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Rivera-Capella, Gretchen (NMSS)
Dickson, Billy (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Rivera-Capella, Gretchen (NMSS)
EN Revision Imported Date: 7/6/2022
EN Revision Text: AGREEMENT STATE REPORT - OCCUPATIONAL OVEREXPOSURE
The following was received from Illinois Emergency Management Agency (the Agency) via email:
"The Agency was notified on 6/24/2022, that an employee at Decatur Memorial Hospital handled a vial of F-18 and may have received an extremity dose in excess of 2.5 Gy (250 rad). The exposure reportedly occurred on Monday, June 20, and was not reported timely. Agency staff will perform a reactionary inspection at 0600 CDT, Monday, June 27, when licensee staff are back on site.
"Agency inspectors were contacted via email by the RSO [(Radiation Safety Officer)] designee for Decatur Memorial Hospital (RML, IL-02444-01) on 6/22/2022, to advise an operator grabbed a reaction vessel vial containing 10 mCi of F-18 FDG [(fluorodeoxyglucose)] for roughly 20 seconds in order to save a production run. NOTE: The reported activity was updated on 6/24/2022, to 10 Ci. Reportedly, the employee was training a new operator and noticed during synthesis, the reaction vessel wasn't placed in the heating apparatus and synthesis would fail. He opened up the mini cells and placed the vessel into the correct spot with his gloved hand. At that time, both Agency and licensee staff estimated the exposure to the hand to be in the range of several hundred millirem to possibly over the 50 rem occupational limit. The licensee was instructed to expedite processing of the employee's extremity and whole-body badges and conduct a time-motion study to determine if occupational limits had been exceeded. During a phone discussion with the licensee on 6/24/2022, the license corrected previously provided information and stated the production vial contained 10 Ci of F-18. Agency staff immediately made a second call to the licensee's on-duty pharmacist to confirm. At 10 Ci, Agency staff estimate the operator's actions may have caused or threatens to cause a shallow dose equivalent to the extremities of 2.5 Gy (250 rad) or more. This is based on a 20 second contact time with a vial containing 10 Ci of F-18 and using a 1cm distance. Clarification will be obtained on 6/27/2022, during a reactionary inspection to perform a time motion study. The Agency is awaiting the dosimetry results."
Illinois Item Number: IL220022
* * * UPDATE ON 7/5/22 AT 1711 FROM GARY FORSEE TO KERBY SCALES * * *
The following update was received from the Illinois Emergency Management Agency (the Agency) via email:
"This is an update to NMED incident EN55961 (Illinois incident number IL220022) where we reported an incident involving the potential for an occupational exposure exceeding 250 rad to the extremities. Agency staff completed a reactionary inspection and received the expedited dosimetry reports from the licensee. A time motion study conducted by Agency staff estimates the occupational exposure at no more than 19 rem to each hand and no more than a few hundred millirem whole body. The dosimetry reports were received and indicated the employee received 100 millirem whole body and an average of 1.2 rem to each hand. We do believe the extremity and whole body badges to be representative of the doses received. Neither our conservative calculations nor the processed dosimetry report indicate this will be an abnormal occurrence. We will update the NMED report and resubmit to INL tomorrow."
Notified R3DO (Lafranzo); NMSS Events Notification, Gretchen Rivera-Capella, and Robert Sun via email.
EN Revision Text: AGREEMENT STATE REPORT - OCCUPATIONAL OVEREXPOSURE
The following was received from Illinois Emergency Management Agency (the Agency) via email:
"The Agency was notified on 6/24/2022, that an employee at Decatur Memorial Hospital handled a vial of F-18 and may have received an extremity dose in excess of 2.5 Gy (250 rad). The exposure reportedly occurred on Monday, June 20, and was not reported timely. Agency staff will perform a reactionary inspection at 0600 CDT, Monday, June 27, when licensee staff are back on site.
"Agency inspectors were contacted via email by the RSO [(Radiation Safety Officer)] designee for Decatur Memorial Hospital (RML, IL-02444-01) on 6/22/2022, to advise an operator grabbed a reaction vessel vial containing 10 mCi of F-18 FDG [(fluorodeoxyglucose)] for roughly 20 seconds in order to save a production run. NOTE: The reported activity was updated on 6/24/2022, to 10 Ci. Reportedly, the employee was training a new operator and noticed during synthesis, the reaction vessel wasn't placed in the heating apparatus and synthesis would fail. He opened up the mini cells and placed the vessel into the correct spot with his gloved hand. At that time, both Agency and licensee staff estimated the exposure to the hand to be in the range of several hundred millirem to possibly over the 50 rem occupational limit. The licensee was instructed to expedite processing of the employee's extremity and whole-body badges and conduct a time-motion study to determine if occupational limits had been exceeded. During a phone discussion with the licensee on 6/24/2022, the license corrected previously provided information and stated the production vial contained 10 Ci of F-18. Agency staff immediately made a second call to the licensee's on-duty pharmacist to confirm. At 10 Ci, Agency staff estimate the operator's actions may have caused or threatens to cause a shallow dose equivalent to the extremities of 2.5 Gy (250 rad) or more. This is based on a 20 second contact time with a vial containing 10 Ci of F-18 and using a 1cm distance. Clarification will be obtained on 6/27/2022, during a reactionary inspection to perform a time motion study. The Agency is awaiting the dosimetry results."
Illinois Item Number: IL220022
* * * UPDATE ON 7/5/22 AT 1711 FROM GARY FORSEE TO KERBY SCALES * * *
The following update was received from the Illinois Emergency Management Agency (the Agency) via email:
"This is an update to NMED incident EN55961 (Illinois incident number IL220022) where we reported an incident involving the potential for an occupational exposure exceeding 250 rad to the extremities. Agency staff completed a reactionary inspection and received the expedited dosimetry reports from the licensee. A time motion study conducted by Agency staff estimates the occupational exposure at no more than 19 rem to each hand and no more than a few hundred millirem whole body. The dosimetry reports were received and indicated the employee received 100 millirem whole body and an average of 1.2 rem to each hand. We do believe the extremity and whole body badges to be representative of the doses received. Neither our conservative calculations nor the processed dosimetry report indicate this will be an abnormal occurrence. We will update the NMED report and resubmit to INL tomorrow."
Notified R3DO (Lafranzo); NMSS Events Notification, Gretchen Rivera-Capella, and Robert Sun via email.