Event Notification Report for January 19, 2023

AGREEMENT STATE REPORT - STUCK SHUTTER

The following information was provided by Alabama Radiation Control (the Agency) via email:

"Licensee reported that a Honeywell model 4202 beta gauge serial number AE1345 was found with shutter stuck in the safe/closed position during routine shutter checks. The gauge's source, an Eckert and Ziegler model PHC.C2, is promethium-147 with 210 millicuries of activity as of 1/9/2023. The maximum exposure rate at 12 inches from the gauge was reported to be 0.03 mR/hr, less exposure than at installation. The licensee reported that no personnel received radiation exposures over background, due to the shutter's position and that the area around the gauge is unoccupied.

"Reported to the Agency 1/10/23.

"Alabama Radiation Control will provide more information as the investigation continues."

AGREEMENT STATE REPORT - LOST SOURCE

The following information was provided by Alabama Radiation Control (the agency) via email:

"Licensee advised that a Troxler 3430 serial number 79905, nominally with 8 mCi of cesium-137 and 40 mCi of americium241/beryllium, was lost leaving a job site in north Alabama. The licensee stated that the gauge fell from the technician's truck. The gauge has not been located as of this reporting.

"The agency received information about this matter the evening of 1/10/23 and the morning of 1/11/2023.

"Alabama Radiation Control will provide more information as the investigation continues."

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

MEDICAL EVENT - PATIENT UNDERDOSE

The following information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

On January 11, 2023, a patient was administered a Y-90 Therasphere treatment to segments 5 and 8 of the liver. The prescribed dose was intended to be 1.377 GBq. The patient only received a dose of 0.903 GBq. At the time of notification, the licensee suspects that a low flow rate caused an occlusion in the catheter, resulting in less than the prescribed dose of Y-90 being administered to the patient. There were no reported adverse effects for the patient.

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.

AGREEMENT STATE REPORT - TWO UNDER DOSES AND CONTAMINATED INDIVIDUAL

The following information was provided by the Washington Office of Radiation Protection via email:

"This is an event report involving two patients and a technologist [which occurred on 12/14/2022].

"The first patient was being treated for prostate cancer with the radiopharmaceutical PLUVICTO (lutetium-177 vipivotide tetraxetan). The apparatus that is normally used for administering the radiopharmaceutical was not available due to supply chain issues, so a similar apparatus where the infusion vial would be pressurized was used instead. Unfortunately, the radiopharmaceutical began to leak out of the rubber septum of the vial and into the shielded storage container. As soon as the leak was identified, the pump was stopped and the case was aborted, resulting in the dosage delivered being less than the prescribed dose by more than twenty percent. 200 millicuries had been prescribed, but only 129 millicuries was administered to the patient. There may have been too much pressure in the vial, which forced the liquid out of the pierced septum near the needles.

"The patient will continue receiving the remainder of their planned treatments. The effects and appropriate response to missing a partial dose will be discussed with the care team and the drug manufacturer. (The typical recommended treatment is 200 millicuries every six weeks for up to six doses.) The licensee will use a different administration method and apparatus that uses a syringe pump instead of a pressurized vial.

"The second patient was being treated for prostate cancer with the radiopharmaceutical PLUVICTO (lutetium-177 vipivotide tetraxetan). The apparatus that is normally used for administering the radiopharmaceutical was not available due to supply chain issues, so a similar apparatus where the infusion vial would be pressurized was used instead. Unfortunately, radiopharmaceutical began to leak out of the rubber septum of the vial and into the shielded storage container. As soon as the leak was identified, the pump was stopped and the case was aborted, resulting in the dosage delivered being less than the prescribed dose by more than twenty percent. 200 millicuries had been prescribed, but only 121 millicuries was administered to the patient. There may have been too much pressure in the vial, which forced the liquid out of the pierced septum near the needles.

"Due to a cancellation, on the next day (12/15/2022) a dose of PLUVICTO was available and after consultation with the patient, the nuclear medicine team including other authorized users, and the referring physician, it was agreed to inject a partial dose so that the full 200 millicuries originally prescribed would be delivered. The clinical team agreed on the medical necessity and safety of this fractionated administration. The second infusion was completed without incident and was well tolerated by the patient.

"At the manufacturer's web site in the prescribing information for PLUVICTO, a few options are given for administering PLUVICTO. None of those options involve pressurizing the vial of PLUVICTO. This does not appear to be a good practice, and appears to have resulted in the leak.

"Unfortunately, one of the technologists involved in the cleanup of the radiopharmaceutical spills [from the leaking vials] had contamination on his hand that he and radiation safety staff were unable to remove. The Washington State Department of Health has asked for additional details on how the contamination occurred, the radiation readings, and dose estimates, and suggested contacting the U.S. Department of Energy's Radiation Emergency Assistance Center / Training Site for help with dose calculations, decontamination advice, and advice on any additional medical care that the technologist may need in the future because of his radiation dose."

Washington Report Number: WA-23-002

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.

UNINTENTIONAL HIGH-LEVEL SCRAM

The following information was provided by the licensee via email:

"[An] iodized table salt [sample] was inserted to centerline at 1222 (MST) to be irradiated at 4.0 watts. At 1227 the reactor was established as critical at 4.0 watts. The iodized table salt was irradiated until 1320. At 1320 the senior reactor operator communicated to a licensed operator that the salt would be removed. The senior reactor operator pulled the salt out with the power level at 4 watts. The reactor then entered a positive period and jumped to 6.0 watts, resulting in an unintentional high-level scram. The senior reactor operator called the chief supervisor and alerted him immediately of the event who then advised to create a report of the event. The chief supervisor then advised that in the future, better communication is necessary to account for the reactivity differences between an inserted sample and the inserted fuel rods. This event will be added to 'Lessons Learned' for future trainees."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

The licensee notified the NRR Project Manager (Helvenston).
All reactor systems responded as designed.