Event Notification Report for August 13, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/12/2021 - 08/13/2021
Agreement State
Event Number: 55464
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: University of Washington Environmental Health and Safety
Region: 4
City: Seattle State: WA
County:
License #: C001
Agreement: Y
Docket:
NRC Notified By: Tristan Hay
HQ OPS Officer: Brian Lin
Licensee: University of Washington Environmental Health and Safety
Region: 4
City: Seattle State: WA
County:
License #: C001
Agreement: Y
Docket:
NRC Notified By: Tristan Hay
HQ OPS Officer: Brian Lin
Notification Date: 09/15/2021
Notification Time: 14:19 [ET]
Event Date: 08/13/2021
Event Time: 00:00 [PDT]
Last Update Date: 09/15/2021
Notification Time: 14:19 [ET]
Event Date: 08/13/2021
Event Time: 00:00 [PDT]
Last Update Date: 09/15/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
AZUA, RAY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
CNSC (CANADA), - (EMAIL)
AZUA, RAY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
ILTAB, (EMAIL)
CNSC (CANADA), - (EMAIL)
EN Revision Imported Date: 10/15/2021
EN Revision Text: AGREEMENT STATE REPORT - MISSING RADIOACTIVE SOURCES
The following is summary of information received from the state of Washington via email:
On August 13, 2021, the University of Washington Radiation Safety concluded that it was unable to locate two Gd-148 sources with activity totaling 0.0882 microCi and one Am-241 source with activity 0.982 microCi. Internal radiation exposure to these sources is highly unlikely, and any external exposure to the sources would not be considered a public health and safety concern. It is probable that the sources are still in the facility, but since they cannot be located they are considered missing. The root cause of the problem is a lack of documentation of source use and storage locations. Corrective actions were taken by Radiation Safety to prevent future loss of material.
WA incident no.: WA-21-021
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 Text: AGREEMENT STATE REPORT - MISSING RADIOACTIVE SOURCES
The following is summary of information received from the state of Washington via email:
On August 13, 2021, the University of Washington Radiation Safety concluded that it was unable to locate two Gd-148 sources with activity totaling 0.0882 microCi and one Am-241 source with activity 0.982 microCi. Internal radiation exposure to these sources is highly unlikely, and any external exposure to the sources would not be considered a public health and safety concern. It is probable that the sources are still in the facility, but since they cannot be located they are considered missing. The root cause of the problem is a lack of documentation of source use and storage locations. Corrective actions were taken by Radiation Safety to prevent future loss of material.
WA incident no.: WA-21-021
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
Event Number: 55406
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY
Licensee: Loyola University Medical Center
Region: 3
City: Maywood State: IL
County:
License #: IL-01131-02
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Howie Crouch
Licensee: Loyola University Medical Center
Region: 3
City: Maywood State: IL
County:
License #: IL-01131-02
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Howie Crouch
Notification Date: 08/13/2021
Notification Time: 16:44 [ET]
Event Date: 08/13/2021
Event Time: 00:00 [CDT]
Last Update Date: 08/13/2021
Notification Time: 16:44 [ET]
Event Date: 08/13/2021
Event Time: 00:00 [CDT]
Last Update Date: 08/13/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
SKOKOWSKI, RICHARD (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
SKOKOWSKI, RICHARD (R3)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 9/13/2021
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was obtained from the Illinois Emergency Management Agency (the Agency) via email:
"Loyola University Medical Center contacted the Agency this afternoon to report a medical underdose of Lu-177 that occurred today, August 13, 2021. Although information provided was preliminary, no untoward medical impact is expected to the patient.
"[The] Radiation Safety Officer for the licensee contacted the Agency at approximately 1500 CDT on August 13, 2021, to report that a patient scheduled to receive 200 mCi of Lu-177, Lutathera therapy for neuroendocrine tumors, received only 14 percent of the dose prescribed (28 mCi) in the written directive. The underdosing was intentionally aborted by the authorized user after the patient advised they had received the planned chemotherapy injection the day before, rather than after the radiopharmaceutical administration per procedure. The licensee is investigating root cause. The licensee is calculating organ dose to the kidney, but preliminary estimates are 67 rad. If the dose falls beneath 50 rad, the incident may be retracted. Notification to the patient and the referring physician has been completed. Agency inspectors are awaiting additional information but plan a reactive inspection within 10 days. The reporting requirements for the licensee, as specified in 32 Ill. Adm. Code 335.1080(c) were met, and the licensee is aware of the need for a written report within 15 days. This report will be updated as additional information becomes available."
Illinois NMED Report No.: IL210024
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 Text: AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was obtained from the Illinois Emergency Management Agency (the Agency) via email:
"Loyola University Medical Center contacted the Agency this afternoon to report a medical underdose of Lu-177 that occurred today, August 13, 2021. Although information provided was preliminary, no untoward medical impact is expected to the patient.
"[The] Radiation Safety Officer for the licensee contacted the Agency at approximately 1500 CDT on August 13, 2021, to report that a patient scheduled to receive 200 mCi of Lu-177, Lutathera therapy for neuroendocrine tumors, received only 14 percent of the dose prescribed (28 mCi) in the written directive. The underdosing was intentionally aborted by the authorized user after the patient advised they had received the planned chemotherapy injection the day before, rather than after the radiopharmaceutical administration per procedure. The licensee is investigating root cause. The licensee is calculating organ dose to the kidney, but preliminary estimates are 67 rad. If the dose falls beneath 50 rad, the incident may be retracted. Notification to the patient and the referring physician has been completed. Agency inspectors are awaiting additional information but plan a reactive inspection within 10 days. The reporting requirements for the licensee, as specified in 32 Ill. Adm. Code 335.1080(c) were met, and the licensee is aware of the need for a written report within 15 days. This report will be updated as additional information becomes available."
Illinois NMED Report No.: IL210024
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.