Event Notification Report for December 16, 2021

EN Revision Imported Date: 12/16/2021

EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE OF Y-90

The following was received from the Commonwealth of Pennsylvania by email:

"On December 6, 2021, a patient underwent a Y-90 TheraSphere treatment. There were no apparent issues during the treatment, but the four-sided equipment readings before and after treatment indicated that only 63% of the prescribed dosage got into the patient. The prescribed dose was 4.08 GBq and the calculated received dose was 2.57 GBq. Preliminarily the licensee believes there was a flow issue and the micro catheter caused some of the material to precipitate out. The licensee is currently investigating to determine if that is the cause. The patient and physician have been informed. No adverse effects to the patient are anticipated."

PA Event Report ID No: PA210019

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: 12/16/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGNS

The following was sent by the state of Colorado by email:

Two Tritium (H-3) exit signs (6.2 Ci each) reported as lost on annual registration 12/07/2021.


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: 12/16/2021

EN Revision Text: AGREEMENT STATE REPORT - LOST TROXLER DENSITY GAUGE

The following information from the state of Utah Division of Radiation Control (Division) was received by email:

"A licensee gauge operator lost/misplaced a Troxler portable nuclear density gauge model 3411 (SN 12109), [containing 8 mCi of Cs and 40 mCi of Am-Be]. He claims he arrived at the licensee laboratory and signed his gauge out on the shipping log at 0615 [MST]. He then took his gauge within the transportation case outside of the secured storage room and set it down on the floor inside the laboratory next to the storage room and proceeded to load additional equipment into his truck parked out back. He was outside loading this equipment and was having a conversation with another employee. The other employee said he had to leave and the gauge operator said he had to leave also and got in his truck and drove to his first project at 0630 [MST]. At his first project site in Riverton, he then realized he had forgotten the gauge at the lab. At 0730 [MST] he left the project and drove back to the lab to discover that the gauge was not there on the floor at approximately 0830 [MST]. He searched the lab, storage room, and questioned lab personal. The RSO was informed of this situation at 0850 [MST].

"The licensee has notified law enforcement of the missing gauge. The Division is waiting for additional information from the licensee."

UT Event Report ID No.: UT-21-0007


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: 12/16/2021

EN Revision Text: NON-AGREEMENT STATE REPORT - DOSE MISADMINISTRATION

The following is a summary of information received via telephonic conversation from the Radiation Safety Officer at Saint Vincent Indianapolis Hospital:

At 1000 EST on December 8, the health physicist became aware that on the previous day a patient was treated with the wrong plan parameters. The patient was given a dose on the same organ as the assigned patient on the treatment report with nearly the same prescribed dose. The total dose was 3030 cGy, which is 1 percent higher than the prescribed dose of 3000 cGy that the patient was prescribed. The treatment was completed with no unintended harm to the patient. The second patient was not affected by the error. The event is being reported under 10CFR35.3045(a)(2) for an administration of a dose or dosage to the wrong individual.

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: 12/16/2021

EN Revision Text: NON-AGREEMENT STATE REPORT - LOST TRITIUM RANGE INDICATOR

The following is a summary of telephonic information received from the U.S. Army:

On December 9, 2021, the Radiation Safety Officer (RSO) was notified that a range indicator for a mortar system, containing a 3.2 Curie Tritium source, had been lost for over a year at the Iowa National Guard in Johnston. The indicator is not removable, so it is unclear how it was lost. Army leadership became aware on November 3, 2021, and a search began. The RSO was notified that the search was concluded, and the source is considered lost.

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: 12/16/2021

EN Revision Text: AGREEMENT STATE REPORT - NOTIFICATION OF ABANDONMENT OF WELL LOGGING SOURCES

This information was provided by via email from LA Department of Environmental Quality (LDEQ):

"On December 8, 2021, LDEQ was notified by Halliburton Energy Services, Inc., Senior Radiation Safety Officer via email concerning well logging sources that were abandoned downhole. According to the RSO, the two sources were one 555 GBq (15 Ci) Eckert and Ziegler Model LWD4173, source s/n EZ16008 and one 74 GBq (2.0 Ci) QSA Global, Model CDC.CY13, source s/n 54903B. Halliburton was performing directional drilling for Whitney Oil & Gas LLC. The well was in inland waters. The date of occurrence was November 16, 2021. Well Name and Registration: Well No. 138 and 17721205480000."

Event Report ID No.: LA 202100011

FAILED FITNESS FOR DUTY TEST

* The following information was provided by the licensee via email:

"At 0927 EST on December 15, 2021, it was determined that a non-licensed employee supervisor failed a test specified by the fitness for duty (FFD) testing program. The individual's authorization for site access has been terminated. The NRC Resident Inspector has been notified."