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hospital contamination incident
Please note the attached hospital contamination incident from the NRC,
"Event Notification Report for December 26, 2002."
1. All of you hospital hp's out there should be aware of this incident,
and assess your vulnerability to a similar incident.
2. It seems that the NRC is focusing on one tree and ignoring the
forest. The real issue is not whether the nuclear medicine tech changed
her gloves before handling the package. The real issue is the
hospital's radiological controls, specifically: Why wasn't the box
surveyed before being presented for transportation? (If it was
surveyed, the survey was clearly less than adequate.) If the box was
shipped as radioactive "empty packaging," a survey was needed to assure
that it met the requirements for that shipping category. If the box was
shipped as nonhazardous, it should have been surveyed before being
released from the restricted area. If I were the RSO, I'd be concerned
about other contaminated items being released from the nuclear medicine
department.
3. This is how public trust is lost and why we end up being
overregulated. It's NOT a media conspiracy.
The opinions expressed are strictly mine.
It's not about dose, it's about trust.
Curies forever.
Bill Lipton
liptonw@dteenergy.com
Hospital |Event Number:
39471 |
+------------------------------------------------------------------------------+
+------------------------------------------------------------------------------+
| REP ORG: COLORADO DEPT OF PUBLIC HEALTH |NOTIFICATION DATE:
12/24/2002|
|LICENSEE: UNIVERSITY HOSPITAL |NOTIFICATION TIME:
17:57[EST]|
| CITY: DENVER REGION: 4 |EVENT DATE:
12/12/2002|
| COUNTY: STATE: CO |EVENT
TIME: [MST]|
|LICENSE#: 828-01 AGREEMENT: Y |LAST UPDATE DATE:
12/24/2002|
| DOCKET:
|+----------------------------+
| |PERSON
ORGANIZATION |
| |LINDA HOWELL
R4 |
| |SUSAN FRANT
NMSS |
+------------------------------------------------+
|
| NRC NOTIFIED BY: BRIAN VAMVAKIAS
| |
| HQ OPS OFFICER: MIKE RIPLEY
| |
+------------------------------------------------+
|
|EMERGENCY CLASS: NON EMERGENCY
| |
|10 CFR SECTION:
| |
|NAGR AGREEMENT STATE
| |
|
| |
|
| |
|
| |
|
| |
+------------------------------------------------------------------------------+
EVENT TEXT
+------------------------------------------------------------------------------+
| AGREEMENT STATE REPORT - DELIVERY DRIVER CONTAMINATED WHEN HANDLING
SHIPMENT |
|
PACKAGES
|
|
|
| On 12/12/02 a Mallinckrodt, Inc. delivery driver was contaminated
with |
| Iodine-131 due to handling three packages picked up from University
Hospital |
| in Denver, CO. The contamination was discovered upon the driver's
return |
| to the Mallinckrodt facility. The driver's hands were
successfully |
| decontaminated and subsequent bioassays indicated no readings above
action |
| levels. The three contaminated packages and the driver's lab coat
were |
| bagged and isolated. No further contamination was found.
Upon |
| investigation, it was determined that a nuclear medicine technologist
at |
| University Hospital had contaminated her gloves while handling an
I-131 |
| capsule and then handled the shipping boxes without changing her
gloves. |
+------------------------------------------------------------------------------+
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