Event Notification Report for August 10, 2023

EN Revision Imported Date: 8/10/2023

EN Revision Text: MEDICAL EVENT - DOSE TO UNINTENDED ORGAN

The following is a summary of information provided by the licensee via telephone:

A patient was prescribed Y-90 microsphere implants to the liver. The procedure occurred on 4/20/23 with no abnormal outcomes reported. The patient returned to the hospital on 7/24/23 reporting stomach pain which was diagnosed as an ulcer. A biopsy of the ulcer revealed microspheres. Due to the tissue damage, it was assessed that the dose to the stomach lining exceeded 50 Rem. This event is being reported per 10 CFR 35.3045(a)(3).


* * * RETRACTION ON 8/9/23 AT 1405 EDT FROM CHRISTIANA CARE HEALTH SYSTEM TO KAREN COTTON * * *
The following information was provided by the licensee via telephone:
The Radiation Safety Officer called the NRC Headquarters Center at 1405 EDT to retract Event 56638. NRC and Christiana, the licensee, assessed the event, and determined that it was due to shunting, and thus did not meet the criteria of a medical event.

Notified R1DO (Dimitriadis) 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.

RADIOACTIVE SOURCE LOST IN TRANSIT

The following information was received from Elkhart Clinic via telephone:

A 300 micro-curie germanium-68 (Ge-68) phantom source was sent from Elkhart Clinic of Elkhart, Indiana, in Siemens Medical Solutions in Knoxville, Tennessee, via [common carrier] on November 22, 2022. The radioactive source never arrived at its destination and was subsequently declared lost by [common carrier]. Ge-68 is used as a quality control source for positron emission tomography (PET) studies.

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.pdfNON-

AGREEMENT STATE REPORT - FIXED GAUGE SHUTTER STUCK IN THE ON POSITION

The following information was provided by the Washington State Office of Radiation Protection via email:

"During the semi-annual routine shutter tests on a fixed gauge, the gauge was found to be stuck in the 'ON' position. This malfunction did not pose any additional risk to personnel in the 'ON' position; it only inhibited the ability to lock the gauge in the 'OFF' position for maintenance. The gauge manufacturer was contacted, and a service engineer was able to move the source tube assembly to the 'OFF' position by applying lubricant to the handle rod and gently twisting and pulling on it. This event appears to have occurred due to a lack of lubricant on the handle rod, or from the dust conditions that the gauge is located in, resulting in the source tube assembly becoming stuck inside the source housing. Going forward, a few drops of lubricant will be added during the semi-annual shutter checks to prevent the source tube assembly from becoming stuck again."

There were no personnel overexposures due to this event.

Device/Source Details: VEGA Americas, Inc., model number: HLG-2, serial number: 13570676, containing a 2 Ci (original activity) Cs-137 source.

Reference Document Number: WA-23-013.

AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The following report was received by the California Department of Public Health , Radiation Health Branch (RHB) via email:

"On 08/01/23, a portable moisture density gauge containing radioactive materials (Humboldt Model 5001C082, Serial number HIS 1767, containing 10 mCi Cs-137 and 40 mCi Am-241/Be) was run over by a piece of heavy equipment, on a construction site. The licensee cordoned off the area where the gauge was damaged and contacted Pacific Nuclear Technology (PNT) for assistance. The top shell of the gauge was crushed and found in several pieces, the source rod was bent, and there was no damage to the area where the Cs-137 source was contained. PNT was able to place the rod containing Cs-137 into its original shielding position. The Am-241/Be source was found undamaged in its original position attached to the base. PNT had surveyed the area using a Ludlum model 3, 44-9 detector, and no radiation levels above background were detected. The gauge was placed in the undamaged transit case (transportation index measured 0.2 mR/hr) and transported to the PNT facility where the gauge was leak tested. The leak test performed on the damaged gauge did not indicate any contamination. Currently, the gauge is in storage awaiting approval for disposal.

"RHB will be following up on this investigation."

California incident number: 080123

FITNESS FOR DUTY TEST

The following information was provided by the licensee via email:

"A licensed (non-active) individual failed to comply with fitness for duty testing policies. The individual's unescorted access was terminated."