Event Notification Report for January 17, 2024

MEDICAL EVENT - Y-90 UNDERDOSE

The following information was provided by St. Luke's Regional Medical Center via email:

"The authorized user was performing a yttrium-90 (Y-90) procedure on January 8, 2024. The prescribed activity to be administered was 3.9 GBq, per the written directive. During the procedure, the authorized user paused the administration when they thought that there may have been a leak in one of the connection points. After verifying that there was no leakage occurring, administration resumed as normal. The post-procedure assay of tubing and vial showed that only 3.1 GBq was delivered. There was no spill involved and all remaining activity was contained within the delivery tube.

"Actual dose to the target volume was still at an appropriate range, per the provider. It is not expected that an additional delivery of Y-90 will be scheduled at this time.

"A representative from TheraSphere has been contacted for post-administration inspection of procedure and equipment."

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.

* * * RETRACTION ON 01/11/24 AT 1547 EDT FROM SCOTT FULLER TO IAN HOWARD * * *

"After further review of the administration records, patient and organ doses, and administered activities, along with a better understanding of the Y-90 Licensing Guidance, we are requesting that this event notification be withdrawn."

Notified R4DO (Gaddy), NMSS Events (email).

AGREEMENT STATE - SHUTTER STUCK IN OPEN POSITION

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

"On January 9, 2024, the Department was notified by the licensee's radiation safety officer (RSO) that during routine checks, the shutters on three Vega America SH-F2 source holder failed to close. Open is the normal operating position for the gauges. Each gauge contains a 200 millicurie cesium-137 source. The gauges do not create an exposure risk to any individual. The RSO stated they have contacted a service provider for repairs to the gauges. Additional information will be provided as it is received in accordance with SA300."

Texas Incident Number: I-10076

NMED Number: TX240001

AGREEMENT STATE - STOLEN GAUGE

The following information was provided by the California Department of Public Health, Radiation Health Branch via email:

"On January 8, 2024, the licensee's radiation safety officer contacted the California Office of Emergency Services to report a moisture/density gauge was stolen from a vehicle (Honda Pilot SUV) that was parked at the operator's residence. The gauge transport case was locked, as was the gauge inside the case, and the case was secured to the frame of the locked vehicle with a lock and chain. The gauge was a CPN model MC-3, serial number M339028680 containing 10 mCi Cs-137 (nominal) and 50 mCi Am:Be-241 (nominal). A police report was submitted to the Orange County Sherriff's Department. An advertisement has been submitted to the Orange County Register with a reward for return of the gauge. The licensee's investigation into this event is ongoing and will be reviewed further by the California Department of Public 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 REPORT - IMPROPER SHIPMENT HANDLING

The following is a summary of information provided by the Washington State Department of Health via email:

A shipment from Environmental Management and Controls, Inc. (EMC) to a commercial low-level radioactive waste (LLRW) disposal site near Richland, Washington, was identified as violating Department of Transportation regulations, Washington administrative code, and the LLRW disposal site license. Specific violations were (1) improper transportation vehicle utilized for a shipment with surface radiation greater than 200 mrem/hr, (2) two containers arrived with higher than manifested surface radiation levels, and (3) one container arrived with lower than manifested radiation levels.

The Washington Department of Health issued a notice of violation to the licensee which detailed required remediation including root cause analysis, corrective action plan, and a quality assurance plan in a written response. The licensee use of the LLRW disposal site was also suspended pending a passing inspection by the state of Washington. This incident was not a contamination event and is under investigation.

Washington Incident Number: WMS-DOT-23-07