Event Notification Report for May 28, 2021

EN Revision Imported Date: 5/28/2021

EN Revision Text: AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The following was received from the state of Minnesota via email:

"Only 48.63 Gy was delivered out of the 120 Gy prescribed to the patient [liver]. It appears that 1.8 GBq of the prescribed 2.95 GBq of Y-90 microspheres remained in the delivery device after removal from the patient. Only 1.15 GBq was delivered."


Minnesota Event Report ID: MN-21-0003


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.

EN Revision Imported Date: 5/28/2021

EN Revision Text: PATIENT UNDERDOSE

The following e-mail was received from the Radiation Safety Officer (RSO) at Kootenai Health:

"A misadministration occurred at Kootenai Health in the Interventional Radiology Lab (ID 83814) during a Therasphere Y-90 Microsphere treatment. The prescribed dose was 66.36 mCi to segment 8 of the liver. The microspheres infusion started at 0943 PST when the micropsheres became visually clumped in the tubing of the administration set (distal to the box, prior to the microcatheter connection). Troubleshooting methods were performed, but the microspheres did not move through the tubing with multiple saline flush attempts. The infusion was aborted at 1016 PST. The room was surveyed per protocol and there was no contamination. The jar containing the tubing and microcatheter were measured per protocol. Calculations determined the patient received 12.8 mCi which was 20 percent of the prescribed dose. The RSO was notified at 1058 PST, the referring physician [was notified] at 1128 PST, and the patient [was notified] at 1150 PST."

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.

EN Revision Imported Date: 5/28/2021

EN Revision Text: LOST, THEN FOUND, PACKAGE OF IODINE-131

The following is a summary of a phone conversation with the Licensee's Radiation Safety Officer (RSO):

RLS (USA) Inc was informed that a package, which was shipped via a common carrier, was delivered to the wrong address. The package, which contained a sealed source of 297 millicuries of I-131, was dropped off at approximately 0930 (EDT) to Valassis Anderson Printing Plant. The package was labeled with the correct address, however the common carrier delivered it to the wrong location. Valassis Anderson Printing Plant informed the Licensee (RLS) at 1330 that they were in possession of the mis-delivered package at which time the Licensee immediately picked up the package and brought it to their facility. The package was missing for approximately 4.5 hours. Upon inspection, the package was not damaged. Wipes taken were at background levels. A surface survey reading indicated 17 mrem/hr and the transportation index was .5.

The contents of the package are 1000 times the limit specified in appendix C to part 20.

The RSO performed a worst case scenario: If a member of the public held on to the package for 4.5 hours that would yield a dose of approximately 76.5 millirem. The more likely scenario is that a member of the public was at 3 meters from the package for 4.5 hours which would yield a dose of 2.25 millirem. It is estimated that a member of the public could have received a dose greater then 2 millirem in 1 hours. However, there is no way to confirm this.

The package originated from Jubilant Draximage, Canada.




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

EN Revision Imported Date: 5/28/2021

EN Revision Text: REPORT OF OFFSITE NOTIFICATION

"Event meets ACD2-RG-044 App. B N.1 'The licensee shall notify the NRC Operations Center of any event or situation, related to the health and safety of the public or onsite personnel, or protection of the environment, for which a news release is planned or notification to other government agencies has been or will be made. Such an event may include an on-site fatality or inadvertent release of radioactively contaminated materials.'

"Received preliminary notification from TestAmerica Colorado that there was an exceedance of the Total Suspended Solids NPDES [National Pollution Discharge Elimination System] permit limit at Outfall 013. This was not unexpected with the current state of the settling pond above Outfall 013. An Ohio EPA [OEPA] 24 Hour non-compliance notification form was filled out and sent it to our OEPA NPDES inspector.

"Notification concurrent to the OEPA notification."