Event Notification Report for December 15, 2022

AGREEMENT STATE REPORT - LOST EXIT SIGNS

The following information was provided by the Nebraska Dept. of Health and Human Services via email:

The licensee discovered two tritium exit signs were lost. The exit signs are Isolite model SLX60 containing 7.5 Ci of tritium (H-3) each. This is being reported under 10 CFR 20.2202(a)(1)(i).

Nebraska Incident No.: NE220006

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.pd

AGREEMENT STATE REPORT - RADIOPHARMACEUTICAL MISADMINISTRATION

The following report was received from the New Jersey Department of Environmental Protection (NJDEP), via email:

"The licensee had scheduled two patients who were each to receive 200 mCi of Lu-177. One patient was to receive 200 mCi of Lu-177 Lutathera, while the other was to receive 200 mCi of Lu-177 PSMA. The PSMA patient was mistakenly administered the Lutathera, while the Lutathera patient was mistakenly administered the PSMA.

"Licensee is working with Radiation Safety Officer on steps needed to prevent recurrence.

"NJDEP Actions: Will conduct on-site visit if warranted."

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.