Event Notification Report for February 09, 2024

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following is a summary of information received by email from the Illinois Office of Nuclear Safety:

On January 31, 2024, a medical administration of Y-90 microspheres at Rush University Medical Center failed to deliver the intended dose. A patient had been prescribed 34.99 mCi (500 Gy) of yttrium-90 (Y-90) Theraspheres intended for a liver treatment. The post-administration survey indicated a delivered dose of only 23.05 mCi (330 Gy), which was a 34 percent underdose. The patient and physician were notified the day of the treatment. There was no adverse impact on the patient and the patient will not need to be retreated. The administering physician reported significant resistance in the initial and subsequent flushes.
IL NMED Item Number: IL240003
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 - POTENTIALLY DAMAGED GAUGE

The following information was provided by the Colorado Department of Public Health and Environment (the Division) via email:

"On Thursday February 1, 2024, at approximately 1030 MST, the Division was notified of a vehicle collision that resulted in the damage of a portable nuclear gauge (Nuclear Gauge - Troxler 3430 SN: 28355).

"The initial report indicated the Type A package containing the nuclear gauge was thrown from the vehicle and both the package and the gauge sustained damage.

"Colorado State Patrol responded to the scene and determined the nuclear gauge was intact, and it was turned over to the licensee.

"The Department confirmed with the licensee the gauge was able to be secured with the source in the shielded position and the shielding for the sources is not compromised. A leak test is being expedited at this time."

Colorado Event Number: CO 240001

MEDICAL EVENT - OVERDOSE

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

A patient received a Y-90 Therasphere injection to the liver. The procedure was successfully completed with no abnormalities noted. After the procedure, an imaging study was conducted on the patient's liver, and it was determined that the Theraspheres had concentrated in a single segment of the liver (segment 4) when they had been expected to distribute throughout the entire liver. The calculated dose to the single segment would have exceeded the prescribed dose (633 Gy vice 91 Gy) due to the higher concentration of Y-90. The physician and patient were notified. No adverse effect is expected to the patient or the target organ.

* * * RETRACTION ON 2/8/24 AT 1547 EDT FROM VRINDA NARAYANA TO BILL GOTT * * *

After further review, the correct target was irradiated, the correct activity was injected and all procedures were followed. The average dose to the target matched the written directive. Thus, the event was not reportable, and the licensee is retracting the event.

Notified R3DO (Ziolkowski), NMSS Events (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.

AGREEMENT STATE REPORT - LOST SOURCE

The following is a summary of information received from the Georgia Radioactive Material Program (the Department) via email:

The licensee's Assistant Director of Radiation Safety contacted the Department on February 1, 2024, at 1700 EST, to report a missing source. He stated he was notified that morning that a germanium-68 Phantom, for use with a PET/MRI (positron emission tomography/magnetic resonance imaging) machine was reported missing. It has a reference activity of 55 MBq / 1.5mCi. During a follow up call from the Department, the Assistant Director stated the source was delivered and accounted for Monday, January 29, 2024, then reported missing February 1, 2024. The source was in a restricted area and locked in the hot lab. The Assistant Director stated they have created a police report and are awaiting surveillance footage. The licensee believes it may have been thrown away accidentally, therefore they are also searching their dumpsters.

Georgia Incident Number: 77

* * * UPDATE ON 02/06/24 AT 1428 EST FROM STACY ALLMAN TO NATALIE STARFISH * * *

The following is a summary of information received from the Georgia Radioactive Material Program (the Department) via email:

The Assistant Director of Radiation Safety contacted the Department on 02/02/24 to provide an update on the steps being taken to find the lost source. They had informed the police department and opened an investigation. Security was also assisting in the investigation. The radiopharmacy that supports Emory University, called on 02/05/24 and reported their driver accidentally removed the source. The source was returned on 02/05/24 and the Assistant Director of Radiation Safety completed the check in and the leak test on the source.

Notified R1DO (Lilliendahl), NMSS Events Notification, and ILTAB via email.

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/MISSING SOURCE

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

"The Agency was notified 2/2/24, by G.E. Healthcare in Arlington Heights, IL, (RML IL-01109-01) to advise two radiopharmaceutical packages were missing at the Memphis, TN, [common carrier] hub. The first package contained two shielded vials of iodine-123 (I-123), accounting for 66.8 mCi at the time of shipment. The second package contained 1.0 mCi of indium-111 (In-111); but was located in the [common carrier] facility damaged with the contents missing. [Common carrier] staff advise they are actively searching the facility.

"The first radiopharmaceutical package containing two vials of I-123 (and believed to be intact) was shipped 1/29/24 from Arlington Heights, IL, to Nuclear Diagnostic in Budd Lake, NJ. It was last reported at the [common carrier] hub in Memphis, TN, on 1/29/24. The second package believed to be damaged and within the [common carrier] facility was shipped 1/13/24 from Arlington Heights, IL, to RLS USA in Pittston, PA. Missing is a vial of In-111 Oxyquinoline Solution within a 6-mm thick lead-shielded container. The current activity is estimated to be 19.0 microcuries. If unshielded, this vial would present an exposure rate of approximately 1 millirem per hour at three inches. GE Healthcare has been provided photos and a description of the container and inner product. [Common carrier] staff are currently surveying with radiation detection equipment."

Illinois Item Number: IL24004

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

FITNESS FOR DUTY PROGRAMATIC ISSUE

The following information was provided by the licensee via email:

"A programmatic vulnerability, failure, or degradation was discovered within the fitness for duty (FFD) program that may permit undetected drug or alcohol use or abuse by individuals within the protected area, or by individuals who are assigned to perform duties that require them to be subject to the FFD program.

"Public and plant safety have not been affected."

The NRC Resident Inspector was notified.

FITNESS FOR DUTY VIOLATION

The following information was provided by the licensee via email:

A supervisor had a confirmed positive for alcohol during a random fitness for duty test. The supervisor's access to the plant has been terminated.