INES-event
INES 2

Member of the Public Overexposure

The potentially overexposed individual may have spent a significant amount of time visiting his fiancée who was receiving a temporary implant of Cs-137 and Ir-192 seeds via low dose-rate remote afterloader brachytherapy on April 16-18, 2010. The licensee instructed the patient's visitor to visit no longer than 2 hours in a 24-hour period and to stay behind the bedside shield during these visitations. On Tuesday, April 20, 2010, the Assistant Nurse Manager informed the licensee that the visitor claimed to have spent the night in the bed with the patient on two consecutive nights. Nursing Management personnel are in the process of interviewing staff members that were involved directly with the care of the implant patient to verify that the visitor was in the room overnight with the patient. A preliminary and conservative dose estimate for the visitor is 60 mSv (6 rem) whole body exposure, based on a 16-hour stay time (8 hours each night for two nights) and an estimated distance of 15.2 cm (6 inches) from the sources. Investigation of the event continues.Update: the licensee determined the member of the public received 13 mSv (1.25 rem), which is above the 1 mSv (100 mrem) limit for members of the public. The licensee’s corrective action involved major procedural changes and training to medical staff who manage brachytherapy patients.

Location: Ohio State University, Columbus Ohio
Event date: Tue, 20-04-2010
Nuclear event report
Legenda & explanation