Event Notification Report for July 07, 2023

MEDICAL EVENT - PATIENT UNDERDOSE

The following information was provided by the Veterans Health Administration (VHA) National Health Physics Program (NHPP) via phone and email:

"On June 28, 2023, the VHA NHPP was notified of a medical event at the Michael E. DeBakey VA Medical Center, Houston, Texas. The medical center holds VHA permit number 42-00084-06.

"The medical event occurred on June 28, 2023. The event involved the intra-arterial administration of two vials of yttrium-90 (Y-90) microspheres to the liver of a patient. Measurements taken after the procedure of one of the vials, the administration set, and catheter showed an unusually large amount of activity remaining that had not been delivered to the patient. From the measurements, it was estimated that only 28 percent of the prescribed activity for that vial was delivered to the patient. The activity delivered from the other vial was within regulatory requirements. The causes are not certain at this time; the event is under investigation. The patient has been notified. NHPP plans to conduct a reactive inspection regarding the event.

"NHPP will send a written report to NRC Region III in accordance with 10 CFR 35.3045. NHPP has notified the NRC Project Manager for the Master Materials License of NRC Region III."

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 - SOURCE DISCONNECT

The following was provided by the Texas Department of State Health Services (the Agency):

"On June 29, 2023, the Agency was notified by the licensee's radiation safety officer (RSO) that a source disconnect had occurred on June 28, 2023, at a temporary job site. The device (camera) was a SPEC 150 exposure device containing a 43 curie Iridium-192 source. The radiographers had placed the exposure device on an I-beam 15-feet above the floor to shoot a pipe. The device was raised to the pipe using a person lift. After the last shoot, the radiographer removed the guide tube and placed the guide tube and camera in the person lift with them. The radiographer stated they had performed a survey as they approached the camera and said the reading was bouncing up and down. The radiographer stopped halfway up and verified the crank-out indicated that the source was retracted. The radiographer removed the camera and guide tube and lowered them to the floor. Both radiographers noted their self-reading dosimeters were off scale. The radiographers contacted the RSO who had them set up a 2 millirem boundary and a qualified individual then retrieved the source. The source and camera were returned to the licensee's storage location. The radiographers' badges were sent for processing. On June 29, 2023, the RSO reported both radiographers' badges read less than 100 millirem. Additional information has been requested and will be provided as it is received in accordance with SA-300."

Texas Incident No.: 10031
Texas NMED No.: TX230029

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

The following information was provided by the Arizona Department of Health Services (The Department) via email:

"The Department received notification from the licensee about a medical event involving I-131. On June 29, 2023, two patients were scheduled to receive I-131 doses of 75 and 100 millicuries (mCi) each. When the certified nuclear medicine technologist (CNMT) was preparing the first dose for the patient (75 mCi), the CNMT assayed the wrong dose but with the correct paperwork.

"The authorized user was present for the administration and gave the patient a 100 mCi dose of I-131 when the prescribed dose was for 75 mCi. The licensee discovered the mistake prior to giving the second patient (prescribed 100 mCi) the incorrect dose of 75 mCi. The Department has requested additional information and continues to investigate the event."

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 - MEDICAL MISADMINISTRATION

The following information was provided by the Oklahoma Department of Environmental Quality (DEQ) via email:

"On June 26, 2023, a referring physician ordered 300 microcuries for an I-123 thyroid and uptake scan. Instead, outpatient scheduling ordered a 21.1 millicuries Tc-99m sestamibi parathyroid exam. Neither the registration nor the nuclear medicine department reviewed the physician's order, and the Tc-99m sestamibi was administered. Using the nuclear medicine dose tool, the radiation dose estimates provided by the licensee for the I-123 uptake and scan would have been an approximate effective dose equivalent of 0.24 rem with the thyroid being the critical organ receiving 5.20 rad. Using the nuclear medicine dose tool, the radiation dose estimates provided by the licensee for the Tc-99m sestamibi parathyroid exam was an approximate effective dose equivalent of 0.62 rem with the gallbladder being the critical organ receiving 3.83 rad.

"In his email, the radiation safety officer stated that their local steps after this incident will be: to have in-depth conversations with techs and outpatient scheduling manager; initiate an incident report (internal and misadministration form); make notifications to the patient and attending physician; and engage the risk management and internal sentinel event process. The incident will be documented and reviewed in the July radiation safety meeting. It will also be reviewed during the daily facility safety meeting with C-Suites and all facility directors/managers.

"Additional updates will be made as they are received according to SA-300."

DEQ Event #1278

* * * RETRACTION ON 07/05/23 AT 1022 EDT FROM JULIA ROBERTS TO KERBY SCALES * * *

The following is a summary of information provided by DEQ via email:

The event was not a reportable medical event due to not meeting the threshold for reporting under 10 CR 35.3045(a)(1)(ii)(A).

Notified R4DO (Drake) and NMSS Events Notification (email).

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.

MEDICAL EVENT - PATIENT UNDERDOSE

The following information was provided by the licensee via phone and followed up with an email:

"Yesterday, June 29, 2023, from 1201 to 1314 CDT, a Therasphere procedure was performed on a patient. The prescribed dose was for 14.58 mCi of Yttrium-90 (Y-90) to the left lobe of the liver. The authorized user (AU) stated that everything seemed to go normally other than they remembered afterwards a little more resistance than usual while performing the injection. The patient was sent for imaging and it was discovered shortly after 1500 that there was no dose in the patient. This was investigated, and the dose was found to be in the tubing. It is believed that the radioactive particles got clogged within the catheter. The AU stated that the catheter used was a model Trinav 120 cm length catheter, which is a special catheter with anti-reflux basket to prevent reflux and specially designed for Y-90 delivery.

"The AU stated that they would inform the patient of the medical event on the morning of June 30, 2023 (today).

"Additional details will be provided in the 15-day written report."

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 - MISSING RADIOGRAPHY CAMERA

The following information was provided by the New Mexico Environment Department via phone and email:

"Acuren Inspection, Inc., New Mexico Radioactive Materials License IR-448, reported a missing source of licensed material, a lost gamma camera for industrial radiography with an unknown total quantity of radioactivity. The device was lost between the cities of Carlsbad and Jal, New Mexico on Highway 128 around mile marker 38 on June 30, 2023, at approximately 1550 MDT. Crews are actively looking for the missing device.

"The licensee is licensed for gamma cameras with sources of iridium-192 not to exceed 150 curies and selenium-75 not to exceed 100 curies.

"A request for further information from the licensee as events develop has been made."

Notified external: DHS SWO, FEMA Ops Center, USDA Ops Center, HHS Ops Center, DOE Ops Center, DHS CISA Central, and EPA EOC and via E-mail: FDA EOC, Nuclear SSA, FEMA National Watch Center, and CWMD Watch Desk.

THIS MATERIAL EVENT CONTAINS A 'Category 2' LEVEL OF RADIOACTIVE MATERIAL

Category 2 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 a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

UNANALYZED CONDITION

The following information was provided by the licensee via email:

"On July 6, 2023, at 1232 EDT, while operating in Mode 1 at 100 percent power, the supply check valve from the number 2 steam generator to the turbine driven auxiliary feedwater pump was determined during troubleshooting that it is not able to perform its isolation function. This failure would have resulted in the blowdown of both steam generators during a main steam line break in the number 2 steam generator main steam line upstream of the main steam isolation valves until the operators could isolate the faulted steam generator. Previous evaluation has determined that this condition constituted an unanalyzed condition that could impact containment pressure.

"There was no radioactive release to the environment. The steam line from the steam generator to the turbine driven auxiliary feedwater pump was isolated by use of a motor operated valve in the discharge line of the number 2 steam generator. There was no impact to Unit 3 which remains at 100 percent power.

"The Senior Resident was notified.

"This condition is being reported pursuant to 10 CFR 50.72(b)(3)(ii)(B) as a condition that resulted in the nuclear power plant being in an unanalyzed condition that significantly degrades plant safety."