Part 21 Report - 1996-411

ACCESSION #: 9608070003 Beaumont William Beaumont Hospital Royal Oak License Number 21-01333-01: Notification of a Minor Radioactive Spill and Possible Defect Licensee: William Beaumont Hospital, 3601 W. Thirteen Mile Rd, Royal Oak, Michigan 48073 Date/Time of Discovery: April 29, 1996 at 10:00 a.m. A. Description of Event A spill of 60 millicurie of Tc-99m HMPAO occurred at 10:00 a.m. on April 29, 1996 in the Radiopharmacy of the Nuclear Medicine Department. The Radiopharmacy technologist had prepared the radiopharmaceutical kit inside the lead vial shield. The top of the lead vial shield screws into a threaded brass ring located inside the body of the lead vial shield. The technologist picked up the lead vial shield by its top and the brass ring came loose from the body of the lead vial shield. This caused the body of the lead vial shield containing the kit vial (with 60 millicurie of Tc-99m HMPAO) to drop onto the floor. The technologist's shoes, stocking and pants were contaminated and promptly removed. No skin contamination was detected. The spill was contained and decontaminated. An area of residual contamination was shielded with lead foil and covered with absorbent paper for decay. The RSO was notified immediately, and a Spill Report will be completed when the contamination is reduced to background levels. B. Cause of the Spill Although the integrity of each vial and elution shield are routinely checked by the Radiopharmacy staff, with defective components repaired or replaced, the fact that this particular brass ring was loose was not known prior to the spill. The Radiopharmacy technologist picked up the vial shield by its top only in order to transport it to the quality control bench. The weight of the body of the lead shield (i. e., lead pig) coupled with the loose brass ring caused the spill to occur. The lead kit vial shield involved in this spill was several years old and of an older design than currently available vial shields. All lead shields become malleable and more susceptible to loss of their structural integrity over time and with high frequency of use. C. Corrective Actions The manufacturer of the lead vial shield was notified by the RSO on April 29, 1996. The manufacturer redesigned the lead shield in October 1994. In the new design, the brass ring is cemented inside the body of the lead shield with epoxy to prevent it from coming apart. All vial shields designed before October 1994 will be returned to the manufacturer. The manufacturer will replace them with the newly designed vial shields. As part of our routine quality control, each kit and elution vial shield will be checked for structural integrity monthly by the Radiopharmacy staff to prevent this event from recurrence. The Nuclear Medicine staff has been instructed to transport the lead vial shields by the body of the shield, and not just the top. Illegible print Illegible print D. Reporting Requirements This event is being reported to NRC Operations as a possible defect regulated by 10 CFR 21.21 "Notification of failure to comply or existence of a defect and its evaluation." This section required licensees to notify the NRC Operations Center (301- 816-5100) by telephone and within 30 days after making the telephone report, in writing. Notification that is required for a defect should be made as follows: (i) initial notification by fax is the preferred method to NRC Operations Center at (301) 816-5151 within two days following receipt of information of a defect or by telephone; and (ii) written notification within 30 days. Report Prepared by: Cheryl Culver Schultz, M.S. Radiation Safety Officer 810-551-0548 *** END OF DOCUMENT ***

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