Event Notification Report for May 08, 2024

AGREEMENT STATE REPORT - LOST AND RECOVERED MOISTURE DENSITY GAUGE

The following was received from the California Department of Public Health (CDPH) via email:

"On Monday night, April 29, 2024, Converse Consultant's radiation safety officer (RSO) reported the loss of a Troxler moisture density gauge (model 3440, serial 31135) containing sealed sources of Cs-137 (8 mCi) and Am-241:Be (40 mCi). The loss was noticed by the authorized user (AU), after he returned to the Redlands office from a jobsite in Jarupa Valley. The AU admitted that he must have left the Troxler gauge on his tailgate when taking a phone call in the cab of his truck, then left the jobsite for the day and forgot to put the gauge back into its type A case before transport. The AU told the RSO he retraced his travel route but did not locate the gauge that night. The RSO notified the Riverside County Sheriff of the missing gauge and notified CDPH of the loss at 1843 [PDT]. Upon returning to the jobsite the next day, the construction workers found the gauge. Apparently, the gauge fell off the tailgate within the jobsite, and the construction workers found the gauge and held it in storage until the AU returned to the jobsite. The gauge handle was locked into the safe/shielded position when it fell off the tailgate, and the source rod remained in the shielded position after the fall. The gauge case and electronics sustained minor damage. The AU took the recovered gauge to a service provider (Maurer Technical Services) on April 30, 2024, for leak testing and damage assessment for the minor case/electronic damage. The licensee will report the leak test results to CDPH when they become available. The licensee will gather additional information for the follow up investigation and provide additional information to the CDPH as it becomes available."

California control number: 24-2488

LOST IODINE-125 IMPLANT SEED

The following is a synopsis of information provided by the licensee via phone call:

On 4/15/24, a 145 microcurie iodine -125 implant seed was lost. The seed was one of four seeds to be implanted for mammography. During the exam, it was discovered that only three seeds were implanted. Licensee staff verified that the seed was not implanted in the patient. A thorough survey of the room, linens, and trash was performed and did not yield the seed. Licensee staff can not verify that the seed was present in the needle prior to the procedure.

The patient and the prescribing physician were made aware of the missing seed. No negative effect on the patient is expected.

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

UNPLANNED CONTAMINATION
The following information was provided by the licensee via telephone:
On March 26, 2024, at 0800 EDT, a spill occurred outside of the Cardinal Health facility's hot-cell. The spill was an aqueous thorium suspension containing 0.5 microcuries, Th-229 and 1.0 microcuries, Th-228. The spill was confined to the licensee's facility.
On March 29, 2024, the licensee became aware of a potential airborne radioactivity hazard posed by the spill and directed personnel to wear respiratory protection in the area of the spill. Personnel dosimetry reports indicate that all external radiation exposures were below regulatory limits. Bioassay samples were taken and preliminary bioassay results were below the analytical minimum detectable concentration. Final bioassay results are pending more sensitive analysis.

Decontamination activities were completed on April 12, 2024.

AGREEMENT STATE REPORT - MEDICAL EVENT

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

"On April 30, 2024, the Agency was notified by Northwestern Memorial HealthCare's radiation safety officer of an yttrium-90 (Y-90) TheraSphere underdose. There were no adverse patient impacts reported, and the treatment is scheduled to be repeated the following week. The initial information indicated an underdose of Y-90 TheraSpheres of near 100 percent. Additional information is forthcoming, and Agency staff will be on-site to perform a reactive inspection on May 5, 2024. Updates will be made when available."

IL Event Number: IL240009

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 - OVEREXPOSURE TO AN EMBRYO / FETUS

The following information was obtained from the Illinois Emergency Management Agency (the Agency) via email:

"The Agency was contacted on April 30, 2024, by Advocate Illinois Masonic Medical Center in Chicago, IL, to advise a patient was administered a therapeutic dose of iodine-131 on March 7, 2024, and was confirmed pregnant on April 29, 2024. The licensee estimates the pregnancy began 3-7 days after the iodine administration. Negative pregnancy test results were confirmed prior to the administration. Both the patient and the referring physician were notified on April 29, 2024. Using dose modeling (ICRP-88) methodology, and assuming conception was 3 days post-administration, the Agency estimates dose to the embryo/fetus over the term of the pregnancy to be 19.8 rem. This is based on an effective half-life of 5.5 days over the 3 days from administration. The patient has had a thyroidectomy which complicates the use of available biokinetic models, but likely also alters the effective half-life. The licensee is researching to determine an appropriate value for the effective half-life (which may range down to 14.4 hours and result in a 900 mrem effective dose).

"Agency inspectors will conduct a reactionary inspection, and this report will be updated as additional information becomes available."

IL Report Number: IL240010

RADIOGRAPHY SOURCE DISCONNECT

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

On May 1, 2024, while conducting radiography on a weld using a QSA D880 with a 90 curie iridium-192 source, the source became disconnected from the cable when attempting retrieval. Surveys showed the source was still in the collimator. The radiation safety officer (RSO) set up boundaries and contacted the manufacturer for guidance. After about three hours, the RSO was able to return the source to its shielded container in the radiography camera. Pocket dosimetry indicated that the RSO received a dose of 178 mrem and the assistant RSO received a dose of 12 mrem. Film badge dosimeters will be read to confirm the exposures.