 INES 2 |
External contamination of a worker in a nuclear medicine department |
On 6 March 2026, the Agen-Nerac Hospital Centre reported to ASNR an incident concerning the contamination of a radiographer in the nuclear medicine department whilst preparing for a positron emission tomography (PET) scan.
Whilst drawing a sample from the vial, the medical device failed to draw the full prescribed volume. The vial became overpressurised following the automatic reinjection of the diluted dose into the vial. In order to identify the malfunction, the radiographer disconnected the needles of the sampling kit from the vial. During this procedure, a drop of radioactive solution splashed onto his forehead and another drop onto his glasses.
The worker prioritised continuing with the examinations scheduled for the end of the day and did not carry out his own decontamination until 2:30 hours after the incident. The radiation protection officer was not notified, nor was he asked to carry out the initial decontamination procedures and associated radiological checks.
An analysis of the causes of the incident, carried out by the nuclear medicine department, revealed the absence of a foam wedge, which is normally located beneath the vial supplied by the pharmaceutical laboratory manufacturing the radioactive medicine. Consequently, the incorrect height positioning of the vial caused the misalignment of the sampling and air intake needles, leading to a malfunction of the automatic preparation device.
Furthermore, a dosimetric analysis was carried out by the facility and reviewed by ASNR. The worker was exposed over a very localised area of skin to a dose exceeding the statutory annual exposure limit of 500 mSv to the skin. He was temporarily removed from his workstation, which presented a risk of exposure to ionising radiation, and was referred to a doctor and an occupational health nurse.
ASNR carried out an inspection on 8 April 2026 in the nuclear medicine department to assess the lessons learnt from this incident. The inspectors verified the appropriateness of the corrective actions implemented or planned by the facility to prevent a similar incident from recurring, including in particular the strengthening of the radiation protection culture among workers, compliance with procedures in the event of contamination, and the systematic use of personal protective equipment (PPE) such as gloves and face shields for any intervention on the equipment in the event of a malfunction. The inspectors deemed this action plan satisfactory and will monitor its effective implementation.
ASNR notes that the use of automatic radiopharmaceutical preparation/injection devices significantly reduces workers’ exposure to ionising radiation, particularly to the extremities, but reiterates the need to follow the manufacturers’ instructions for use of medical devices and to adopt appropriate behaviour in the event of contamination. The procedures for training professionals and workplace authorisation must be described in the quality management system for diagnostic nuclear medicine services, in accordance with ASN Decision No 2019-DC-0660 (available online), from 1 July 2019.
Event date: Tue, 17-02-2026
