Event Notification Report for May 16, 2023

AGREEMENT STATE REPORT - LIQUID RADIOACTIVE CONTAMINATION

The following information was provided by Utah Department of Environmental Quality, Division of Waste Management and Radiation Control [the Division], via email:

"The Division was notified of the incident at 7:38 AM on May 8, 2023, by email from the Utah Department of Environmental Quality's duty officer who was on call on Saturday May 6, 2023.

"Information received from the on-call duty officer: The Radiation Safety Officer reported a radioactive material (rubidium-82) release of an unknown amount due to a leaking generator. She said that Cardiac Molecular Imaging found liquid in the bottom of a well chamber of the infusion system. Proper decontamination procedures were followed, the liquid was placed in radioactive waste storage, a wipe test was done, and everything was cleaned up. She said this has happened before. There was no impact to patient treatment. The generator will be shipped back to the manufacturer for investigation. The incident has been contained and there is no immediate threat.

"This appears to be the exact same issue that we notified the NRC for the UT23-0002 and UT23-0003 incidents.

"The Division will investigate this matter and update the record upon completion of the investigation."

Utah Event Report ID No.: UT23-0005

AGREEMENT STATE REPORT - FAILED SHUTTER

The following information was provided by the North Dakota Department of Health, Radiation Control Program via email:

"On 5/8/2023, Minn-Dak Farmers Cooperative in Wahpeton, ND, had an equipment failure on a fixed nuclear gauge (Thermo MeasureTech Model No. 7062) with a 46.7 millicurie Cs-137 sealed source (General Radioisotope Products, Inc. Model No. 850233). The licensee was performing the required routine shutter checks and it was found that shutter on the gauge listed above failed to fully close. There was no visual damage to the shutter, gauge or source at the time of the shutter check. Licensee is in contact with the service provider Vega to replace the gauge."

POTENTIAL MEDICAL EVENT

The following information was provided by the licensee via phone and email:

"In accordance with 10 CFR 35.3045, [Henry Ford Hospital is] reporting a potential medical event.

"On May 8, 2023, a patient was treated with Y-90 TheraSpheres. The total activity prescribed in the written directive was 11.5 mCi to the left lobe of the liver and 11.37 mCi was delivered (99.2 percent). The therapeutic dose was prescribed to be delivered to segment 4 of the left lobe of the liver. During treatment, the position of the catheter was verified and was determined by the physician to be in the correct position. However, post-treatment bremsstrahlung imaging reviewed today on 5/9/2023 indicated some activity was shunted unexpectedly to segments 2 and 3 of the left lobe of the liver. Based on preliminary calculations, this discrepancy could be categorized as a medical event."

* * * RETRACTION FROM ALAN JACKSON TO BILL GOTT AT 0907 EDT ON 05/10/2023 * * *

The following information was provided by the licensee via phone:

Since the exposure was due to shunting, the licensee determined that this event is not reportable in accordance with the licensing guide. This event is being retracted.

Notified R3DO (Feliz-Adorno), NMSS (Rivera-Capella), and NMSS Events Notification.

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.