Event Notification Report for July 21, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/20/2022 - 07/21/2022
Agreement State
Event Number: 56009
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: G.E. Healthcare DBA/ Medi+Physics
Region: 3
City: Arlington Heights State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Karen Cotton-Gross
Licensee: G.E. Healthcare DBA/ Medi+Physics
Region: 3
City: Arlington Heights State: IL
County:
License #: IL-01109-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 07/21/2022
Notification Time: 16:13 [ET]
Event Date: 07/21/2022
Event Time: 00:00 [CDT]
Last Update Date: 07/21/2022
Notification Time: 16:13 [ET]
Event Date: 07/21/2022
Event Time: 00:00 [CDT]
Last Update Date: 07/21/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Kunowski, Michael (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Schroeder, Dan (R1DO)
ILTAB, (EMAIL)
Kunowski, Michael (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Schroeder, Dan (R1DO)
ILTAB, (EMAIL)
AGREEMENT STATE REPORT - LOST RADIOPHARMACEUTICAL PACKAGES
The following information was provided by the Illinois Emergency Management Agency (Agency), via email:
"The Agency was notified on July 21, 2022, by GE Healthcare that four distinct packages (different shipments) were declared as lost while in the care of a common carrier. All four packages contained millicurie quantities of radiopharmaceuticals and were labeled Yellow-II and were last known to be at the carrier's shipping hub in Memphis, TN. All packages were labeled Yellow-II and shipped in a 16cm x 16cm corrugated box from the licensee's facility in Arlington Heights, IL. Package 1 was shipped July 12, 2022, and contained 14.268 mCi of I-123, in route to New Hampshire. Package 2 was shipped July 14, 2022, and contained 4.089 mCi of In-111, in route to California. Package 3 was shipped July 14, 2022, and contained 12.268 mCi of In-111, in route to Florida. Package 4 was shipped July 20, 2022 and contained 0.941 mCi of In-111, in route to Florida. NOTE: The box for Package 4 was located, but its contents are missing. The licensee made timely notification to the Agency. Tennessee program staff will be notified as well."
Item Number: IL220025
THIS MATERIAL EVENT CONTAINS A 'Category 3' LEVEL OF RADIOACTIVE MATERIAL
Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
The following information was provided by the Illinois Emergency Management Agency (Agency), via email:
"The Agency was notified on July 21, 2022, by GE Healthcare that four distinct packages (different shipments) were declared as lost while in the care of a common carrier. All four packages contained millicurie quantities of radiopharmaceuticals and were labeled Yellow-II and were last known to be at the carrier's shipping hub in Memphis, TN. All packages were labeled Yellow-II and shipped in a 16cm x 16cm corrugated box from the licensee's facility in Arlington Heights, IL. Package 1 was shipped July 12, 2022, and contained 14.268 mCi of I-123, in route to New Hampshire. Package 2 was shipped July 14, 2022, and contained 4.089 mCi of In-111, in route to California. Package 3 was shipped July 14, 2022, and contained 12.268 mCi of In-111, in route to Florida. Package 4 was shipped July 20, 2022 and contained 0.941 mCi of In-111, in route to Florida. NOTE: The box for Package 4 was located, but its contents are missing. The licensee made timely notification to the Agency. Tennessee program staff will be notified as well."
Item Number: IL220025
THIS MATERIAL EVENT CONTAINS A 'Category 3' LEVEL OF RADIOACTIVE MATERIAL
Category 3 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf
Agreement State
Event Number: 56010
Rep Org: Minnesota Department of Health
Licensee: Mayo Clinic
Region: 3
City: Rochester State: MN
County:
License #: 1047
Agreement: Y
Docket:
NRC Notified By: Tyler Kruse
HQ OPS Officer: Lloyd Desotell
Licensee: Mayo Clinic
Region: 3
City: Rochester State: MN
County:
License #: 1047
Agreement: Y
Docket:
NRC Notified By: Tyler Kruse
HQ OPS Officer: Lloyd Desotell
Notification Date: 07/22/2022
Notification Time: 12:13 [ET]
Event Date: 07/21/2022
Event Time: 00:00 [CDT]
Last Update Date: 07/22/2022
Notification Time: 12:13 [ET]
Event Date: 07/21/2022
Event Time: 00:00 [CDT]
Last Update Date: 07/22/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Kunowski, Michael (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Burgess, Michele (NMSS)
Einberg, Christian (NMSS)
Kunowski, Michael (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Burgess, Michele (NMSS)
Einberg, Christian (NMSS)
AGREEMENT STATE REPORT - MEDICAL EVENT
The following was received from the Minnesota Department of Health via email:
"A patient was prescribed 100 mCi of Lu-177 Lutathera to treat a metastatic neuroendocrine tumor. On 7/21/2022, the patient received their therapy and was administered 206 mCi by mistake. The root cause of this event is unknown at this time and is being investigated. Based on the additional 106 mCi administration, the licensee calculated the additional whole body effective dose equivalent to be 30.1 rems using ICRP 103 methodology."
MN Event Report ID No. MN330003
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.
The following was received from the Minnesota Department of Health via email:
"A patient was prescribed 100 mCi of Lu-177 Lutathera to treat a metastatic neuroendocrine tumor. On 7/21/2022, the patient received their therapy and was administered 206 mCi by mistake. The root cause of this event is unknown at this time and is being investigated. Based on the additional 106 mCi administration, the licensee calculated the additional whole body effective dose equivalent to be 30.1 rems using ICRP 103 methodology."
MN Event Report ID No. MN330003
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.