Event Notification Report for March 01, 2022

EN Revision Imported Date: 3/1/2022

EN Revision Text: AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT

The following information was provided by the Illinois Emergency Management Agency (Agency) via email:

"At 1400 CST on February 21, 2022, The Carle Foundation notified the Agency to advise of an unreported medical event that occurred on December 28, 2016. No adverse patient impact reported. This will be reported to the NRC this morning.

"Following a comprehensive review of Y-90 Therasphere procedures performed over the last several years, The Carle Foundation d/b/a The Carle Foundation Hospital identified an additional medical event in addition to the one identified during a recent Agency inspection on 2/16/22, that was not reported as required. On 12/28/2016, a written directive to deliver 0.51 GBq Y-90 Theraspheres to the Superior Branch of Segment 3 (liver) was prepared; however, only 0.16 GBq (31.4%) was delivered. The licensee was under the impression that this was not a reportable medical event since they revised the treatment plan and written directive after the procedure. Although still under investigation, the root cause appears to be the use of a smaller microcatheter than recommended. No further treatment to the patient is planned. The authorized user advised that the dose delivered to the critical mass of the segment treated was medically satisfactory for this case."

Illinois Report # IL220006

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: 3/1/2022

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

The following report was received from the California Department of Public Health via email:

"On February 21, 2022, the alternate Radiation Safety Officer of G3 Quality, Inc. contacted the California Office of Emergency Services to report a stolen moisture density gauge. The gauge was a CPN model MC-3 S/N M370108596 (10 mCi Cs-137, 50 mCi Am:Be-241). The gauge was discovered stolen, along with other equipment, from a locked temporary storage container in a fenced (also locked) area of a construction site at the northwest corner of Interstate 10 and Interstate 15. The theft likely occurred sometime between Friday, February 19 and Monday, February 21. The storage container and fence locks were cut. A police report was given to the Ontario Police Department. The licensee's investigation into this event is ongoing and will be reviewed further by the California Department of Public Health."

California Event Number: 022122

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