Event Notification Report for January 20, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/19/2022 - 01/20/2022
Non-Agreement State
Event Number: 55702
Rep Org: Curium US LLC
Licensee: Curium US LLC
Region: 3
City: Maryland Heights State: MO
County:
License #: 24-04206-01
Agreement: N
Docket:
NRC Notified By: Scott Surovi
HQ OPS Officer: Ossy Font
Notification Date: 01/12/2022
Notification Time: 09:44 [ET]
Event Date: 12/10/2021
Event Time: 00:00 [CST]
Last Update Date: 01/12/2022
Emergency Class: Non Emergency
10 CFR Section:
20.2201(a)(1)(ii) - Lost/Stolen LNM>10x
Person (Organization):
Skokowski, Richard (R3)
NMSS_Events_Notification, (EMAIL)
ILTAB, (EMAIL)
Eve, Elise (R1DO)
Event Text
EN Revision Imported Date: 1/20/2022
EN Revision Text: NON-AGREEMENT STATE REPORT - LOST PACKAGES IN TRANSIT
The following is a summary of information received from the licensee via telephonic communication:
On December 10, 2021, 15 packages were scheduled to be delivered by a common carrier to multiple locations in New York. It was then discovered that two packages were missing. The packages contained 44 mCi of Ga-67 and 7.2 mCi of Cu-64, both in liquid form and used for nuclear medicine diagnostic testing. The carrier investigated and searched for the packages but was unable to locate them and they were declared lost on Dec. 17, 2021.
The licensee will notify the Region III office and the New York Department of Health.
THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL
Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
Agreement State
Event Number: 55704
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Northwestern Memorial Hospital
Region: 3
City: Chicago State: IL
County:
License #: IL-01037-02
Agreement: Y
Docket:
NRC Notified By: Robin G. Muzzalupo
HQ OPS Officer: Lloyd Desotell
Notification Date: 01/13/2022
Notification Time: 17:15 [ET]
Event Date: 02/15/2021
Event Time: 00:00 [CST]
Last Update Date: 01/13/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Skokowski, Richard (R3)
NMSS_Events_Notification, (EMAIL)
Event Text
EN Revision Imported Date: 1/20/2022
EN Revision Text: AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following information was received from Illinois Emergency Management Agency (Agency) via E-mail:
"Agency inspectors performed a routine inspection on 1/6/2022. During a review of Y-90 TheraSphere procedures, inspectors noted an unreported medical event which occurred on 2/15/2021.
"On 2/15/2021, a written directive to deliver 1.93 GBq Y-90 TheraSpheres to the right hepatic artery was prepared. The procedure performed that same day was halted prematurely due to an unwinding of the male luer lock connector and only 0.49 GBq were administered. To compensate for the underdose, the licensee created an additional written directive and administered 1.17 GBq Y-90 TheraSpheres without incident [on the same day as the initial procedure].
"The licensee was under the impression that this was not a reportable medical event since they were able to compensate the dose with an additional vial they had on hand and were ultimately able to deliver the intended dose."
Item Number: IL220001
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.