Event Notification Report for April 02, 2024

AGREEMENT STATE REPORT - Y-90 MICROSPHERE MISADMINISTRATION

The following information was provided by the Arkansas Department of Health, Radiation Control Radioactive Material Program (the Agency) via email:

"The radiation safety officer for Central Arkansas Radiation Therapy Institute (CARTI) contacted the Agency on March 21, 2024, to advise of a yttrium-90 (Y-90) microsphere therapy administration in which the patient received 20 percent greater than the prescribed dose. The administration occurred on February 7, 2024. Treatment was only to one side of the liver. The amount was localized to the liver. The physician felt the delivered dose was clinically effective, and no further treatment is planned. No adverse patient impacts are expected.

"The discovery was made during a quarterly review of their written directive on March 20, 2024.

"The Agency is awaiting further information from the licensee."

Arkansas Event #: AR-2024-2

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 - Y-90 THERAPY MISADMINISTRATION

The following information was received from the California Department of Public Health, Radiological Health Branch (RHB) via email:

"On 3/24/24, the alternate radiation safety officer phoned the RHB to report a medical event associated with a yttrium-90 (Y-90) therapy. A patient receiving Y-90 therapy was underdosed by more than 20 percent from the planned dose.

"RHB will investigate."

California Report Number: 032424

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 - FOUND SOURCE

The following information was received from the Washington State Department of Health, Office of Radiation Protection (the Department) via email:

"Action Towing LLC transported a car to the Schnitzer Steel Industries scrap metal facility, and it triggered the scrap yard's radiation detectors. The scrap yard staff measured about 35 micro roentgen/hour on the outside of the car. Officials at Schnitzer Steel Industries contacted the Department which resulted in an evaluation of the concern and issuance of a DOT special permit so that the radioactive car could be returned to Action Towing LLC for proper handling.

"The Action Towing office manager was informed that the staff had seen some sort of radiation equipment in the car, so the Department requested pictures of the equipment. The pictures showed an old military Geiger-Mueller (GM) survey meter and other items. The Department went to Action Towing to investigate the radioactivity. In addition to the old military GM survey meter, which was not radioactive, the Department found two glass tubes containing radioactive material, which measured about 2 milliroentgen/hour on contact. One of the tubes was labeled as radium-226. The Department took the radioactive tubes for disposal, then surveyed the car and found no elevated radioactivity remaining in the car, and therefore released the car for unrestricted use."

WA State Item Number: WA240001

AGREEMENT STATE REPORT - DETACHED SOURCE

The following was received from the Texas Department of State Health Services (the Department) via phone and email:

"On March 26, 2024, the Department was notified by the licensee's radiation safety office (RSO) that earlier this day a radiography crew had a source disconnect while using a SPEC 150 exposure device. The device contained a 23 curie, iridium-192 source.

"The disconnect occurred on the first shot of the day. The RSO reported that the radiographers had completed set up for the first shot but had failed to properly connect the guide tube to the camera. When the radiographers cranked the source out and it hit the collimator, the guide tube popped loose from the camera. The radiographer immediately attempted to crank the source back into the camera but when the source reached the end of the guide tube the source pigtail disconnected from the drive cable.

"The radiographers set up new boundaries and contacted the RSO. An RSO from a nearby office responded to the location. The RSO was wearing a self-reading dosimeter (SRD), alarming rate meter, and TLD [thermoluminescent dosimeter] exposure badge. The RSO placed the camera on the source for shielding, attached the source back to the drive cable, and retracted the source into the camera. The responding RSO's SRD was reading off scale after retracting the source. The badge has been sent to the licensee's dosimetry processor for emergency processing.

"The licensee does not believe any individual exceeded any limit due to this event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident # 10095

AGREEMENT STATE REPORT - LOST EXIT SIGNS

The following is a summary of information received from the Colorado Department of Public Health and Environment via email:

Three SRB Technologies exit signs, model SLXTU1GB10, containing 7.09 curies each of tritium (21.27 curies total) were determined to be lost.

Colorado event number CO240008

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 EXIT SIGNS

The following is a summary of information received from the Colorado Department of Public Health and Environment via email:

Seven Isolite Corporation exit signs, model 2040, containing 11.5 curies each, of tritium (80.5 curies total) were determined to be lost.

Colorado event number CO240007

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