Event Notification Report for August 10, 2021

EN Revision Imported Date: 8/10/2021

EN Revision Text: AGREEMENT STATE REPORT - STOLEN TROXLER MOISTURE DENSITY GAUGE

The following information was received from the state of Nevada via email:

"Authorized user brought a portable nuclear gauge (PNG) up to Reno, Nevada (their license is based out of Las Vegas) to use on job today, August 2, 2021, and stayed the night of August 1, 2021, at the Atlantis, parked in the South East Corner lot. When he went out at 0800 PDT he noticed that the gauge was missing and the chains had been cut. He reported the missing gauge to the [Radiation Safety Officer] RSO and looked around the parking lot, drove the perimeter of the lot and a few blocks around the hotel and did not find the gauge. They notified Reno PD of the stolen gauge and [was notified they] would respond by 0915 PDT (no report number available yet). Atlantis is checking their parking lot security cameras to see if they caught anything on the camera to get a line on the device and fix the time line."

Nevada NMED report number: NV210010

* * * UPDATE FROM COREY CREVELING TO HOWIE CROUCH AT 1923 EDT ON 8/2/21 * * *
The following update was received via email:

"The PNG is from Terracon Consultants, Inc. Sacramento, California office covered by California RML CA 8064-34, and it entered the State of Nevada without reciprocity authorization or shipping papers of any kind. Updated the reciprocity pull down and the license number. Added the police report number [21-13940]. Atlantis Hotel-Casino will provide anything found in their search of security camera footage to Reno Police Department.

Notified R4DO (Gepford) and NMSS 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

EN Revision Imported Date: 8/10/2021

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL UNDERDOSE EXCEEDING 20 PERCENT

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

"Children's Hospital of Chicago Medical Center (IL-01165-01), contacted the Agency on 8/2/21 to advise that a pediatric administration of Y-90 resulted in an underdose exceeding 20%. The incident occurred today, August 2, 2021. No untoward medical impact was expected to the patient.

"The licensee's radiation safety officer designee contacted [the Agency] to advise that a pediatric patient scheduled to receive Y-90 microsphere therapy (Theraspheres) for hepatocellular cancer on August 2, 2021 received only 75 percent of the dose prescribed in the written directive. A Therasphere representative was on site for the administration and did not note stasis. The licensee suspects a kink in the delivery catheter but is currently imaging the RAM waste and tubing to confirm. No personnel or area contamination was reported. It remains to be determined if the dose delivered was clinically effective or if an additional treatment is planned. The patient's father was advised. It is unclear at this point if the referring physician has been notified. Agency inspectors will perform a reactionary inspection tomorrow, August 3, 2021, to assist in determining root cause and gather the additional information required. This matter is reportable under 32 Ill. Adm. Code 335.1080(a)(1)(B). A written report will be required of the licensee within 15 days."

Illinois NMED report number: IL210022

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: 8/10/2021

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL UNDERDOSE EXCEEDING 20 PERCENT

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

"Loyola University Medical Center (IL-01131-02), contacted the Agency on August 3, 2021, to advise that an administration of Y-90 resulted in an underdose exceeding 20 percent. The incident occurred yesterday, August 2, 2021. No untoward medical impact was expected to the patient.

"The licensee's Radiation Safety Officer contacted [the Agency] to advise that a patient scheduled to receive Y-90 microsphere therapy (Theraspheres) for hepatocellular cancer on August 2, 2021 received only 71 percent of the dose prescribed in the written directive. The licensee's Radiation Safety Officer is reviewing the device today as well as the specifics of the administration to determine root cause. The licensee suspects a problem with a connector but is currently investigating. No personnel or area contamination was reported. It remains to be determined if the dose delivered was clinically effective or if an additional treatment is planned. It is unclear at this point if the referring physician or the patient has been notified. An update has been requested within one hour and Agency staff noted the 24 hour notification requirement. Agency inspectors will perform a reactionary inspection, tentatively within a week, to assist in determining root cause and gather the additional information required. This matter is reportable under 32 Ill. Adm. Code 335.1080(a)(1)(B). A written report will be required of the licensee within 15 days."

Illinois NMED report number: IL210023

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.