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RE: hospital contamination incident



This just shows the inconsistency between state agencies...I am aware of

what I consider to be a serious radiological event which was never

reported, to the best of my knowledge, by another state agency...Jim

Nicolosi



Original Message:

-----------------

From: William V Lipton liptonw@DTEENERGY.COM

Date: Fri, 27 Dec 2002 09:00:24 -0500

To: radsafe@list.vanderbilt.edu

Subject: 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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