Event Notification Report for July 29, 2022

The following information was provided by the licensee via email:

AGREEMENT STATE REPORT - SURFACE CONTAMINATION LEVELS EXCEEDED LIMITS FOR PACKAGE

"The licensee, Kettering Health Network, shipped a package containing F-18 FDG [Fluorodeoxyglucose] from their PET [positron emission tomography] manufacturing facility to another hospital listed on their license. Receipt surveys of the package were 110 mR/hr at the surface and 1,050,000 dpm removable. Surveys of the package prior to shipment were 3 mR/hr contact and 210 dpm removable. The licensee uses a radiopharmaceutical company to transport packages. The transport company was notified.

"Surveys of the PET production facility and transport vehicle have been conducted. No contamination was discovered."

Ohio Department of Health - Item Number: OH220008

AGREEMENT STATE REPORT - DOSE MISADMINISTRATION

The following information was provided by the licensee via email:

"This is a preliminary report. A male patient was prescribed 100 millicuries of lutetium-177. He was delivered with 204 millicuries instead on July 20. This was the patient's third round of lutetium-177. The first two rounds were delivered at 100 millicuries as prescribed. Patient has been notified of the misadministration per a phone call from the prescribing physician. Emory University will send a more thorough report of the misadministration. More information is to follow."

Georgia Incident No: 55

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.

AGREEMENT STATE REPORT- LOST EXIT SIGN

The following summary was received from the Colorado Department of Public Health and Environment via email:

The Colorado Department of Public Health and Environment reported one model BX15BK exit sign containing 15 curies of tritium lost by the licensee. The incident occurred June 28, 2022.

CO Event Report ID no.: CO220023

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 REPORT - LOST RADIOPHARMACEUTICAL PACKAGES

The following information was provided by the Illinois Emergency Management Agency (Agency), via email:

"The Agency was notified on July 21, 2022, by GE Healthcare that four distinct packages (different shipments) were declared as lost while in the care of a common carrier. All four packages contained millicurie quantities of radiopharmaceuticals and were labeled Yellow-II and were last known to be at the carrier's shipping hub in Memphis, TN. All packages were labeled Yellow-II and shipped in a 16cm x 16cm corrugated box from the licensee's facility in Arlington Heights, IL. Package 1 was shipped July 12, 2022, and contained 14.268 mCi of I-123, in route to New Hampshire. Package 2 was shipped July 14, 2022, and contained 4.089 mCi of In-111, in route to California. Package 3 was shipped July 14, 2022, and contained 12.268 mCi of In-111, in route to Florida. Package 4 was shipped July 20, 2022 and contained 0.941 mCi of In-111, in route to Florida. NOTE: The box for Package 4 was located, but its contents are missing. The licensee made timely notification to the Agency. Tennessee program staff will be notified as well."

Item Number: IL220025

THIS MATERIAL EVENT CONTAINS A 'Category 3' LEVEL OF RADIOACTIVE MATERIAL

Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

AGREEMENT STATE REPORT - MEDICAL EVENT

The following was received from the Minnesota Department of Health via email:

"A patient was prescribed 100 mCi of Lu-177 Lutathera to treat a metastatic neuroendocrine tumor. On 7/21/2022, the patient received their therapy and was administered 206 mCi by mistake. The root cause of this event is unknown at this time and is being investigated. Based on the additional 106 mCi administration, the licensee calculated the additional whole body effective dose equivalent to be 30.1 rems using ICRP 103 methodology."

MN Event Report ID No. MN330003

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.

AGREEMENT STATE REPORT - LOST SOURCES

The following information was provided by the Illinois Emergency Management Agency (Agency) via email:

"The Agency received a report from the licensee on 7/16/22, indicating the potential loss of (4) brachytherapy seeds, accounting for a maximum estimated activity of 1.02 mCi. The licensee has conducted an investigation and believes the seeds were likely lost or miscounted during patient implant and prior to shipment from a medical facility. Requests for clarification and the nuclide (either I-125 or Pd-103) have not yet been returned. The amount and form of radioactivity would not be useful for illicit intent and there is no indication of intentional theft or diversion.

"DETAILS: On June 29th, 2022, the licensee received a package from a hospital in California (CA). The package contained a source that was outside of the primary container but was found in the corner of the shipping box. The shipping box, reportedly, appeared undamaged from the outside, but the inside lacked appropriate packing materials to cushion the pewter containers. This package was then opened, and all the sources were counted. The hospital sent return fax paperwork saying that the package had six containers from different orders with a total of 218 sources. After fully disassembling all sources from their cartridges, the licensee's staff counted 214 sources. This count at 214 was reverified multiple times by multiple associates. Surveys were also conducted of the licensee's receiving area and returns processing area, as well as, the path in between to verify that the unaccounted-for sources were not in the facility. The hospital staff was contacted to verify the number of sources returned. They responded confirming their records showed they returned 218 sources from six orders but explained that the returned items were packed by other associates prior to their involvement and did not reopen the containers to recount the sources during the shipping process.

"REPORTABILITY: At this time the [4 missing] seeds cannot be attributed to implant, loss in shipment or loss at the CA facility; and is therefore being reported as lost under 32 Ill. Adm. Code 340.1210. It is unclear if the licensee met the reporting window since we are awaiting information on the nuclides involved. The Agency is making notification within 24 hours of becoming aware of the report (email wasn't retrieved until 7/21/22, due to staff absence and the automated reply was not heeded by the notifying party).

"Additional information will be provided as it becomes available."

Illinois Event Number: IL220026

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 REPORT - MISSING MOISTURE DENSITY GAUGE

The following information was provided by the Florida Bureau of Radiation Control via email:

"On 07/22/22 at 1626 EDT, [the Alchua office] Radiation Safety Officer of TRC Engineers called to report that a Troxler 3440 [gauge was shipped] from the Alchua office of TRC to the West Virginia office of TRC via a common carrier. Tracking by the common carrier depicts the package to have arrived at its Memphis facility on 07/22/22 at 1125 EDT. [The package] is reported as delayed/pending per its website. The licensee is working with the common carrier to try to determine why the Troxler Gauge has not been delivered."

Florida Incident Number: FL22-084

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