Event Notification Report for May 18, 2023

AGREEMENT STATE REPORT - MEDICAL EVENT (PATIENT UNDERDOSE)

The following was received from the Colorado Department of Public Health and Environment via email:

"On May 19, 2023, the associate radiation safety officer at the University of Colorado Hospital reported a medical event. The event occurred on May 18, 2023, during a Y-90 TheraSphere administration. The licensee reported that during the administration, there was an obstruction in a line/catheter causing the target to only receive 4.6 percent of the intended dose. The authorized user does not believe the obstruction was due to stasis. The prescribed dose for the treatment was 300 Gy (20.06 mCi) and the administered dose was calculated to be 13.87 Gy (0.93 mCi). The licensee is working with the manufacturer, and the exact cause of the obstruction resulting in the medical event is still under investigation."

Colorado Event Report Number: CO230012

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 - MATERIAL IDENTIFIED IN INVENTORY NOT ON LICENSE

The following report was received by the Florida Bureau of Radiation Control (BRC):

"FSU [Florida State University] contacted BRC Radioactive Materials Licensing via written letter dated May 18th, 2023 regarding a request to add [Uranium] U-233, any form except aerosols, to their license #0032-10. BRC Tallahassee called BRC Orlando this morning at 0900 [EDT] to notify. During a recent inventory close-out process, they found approximately 1.71 mCi of U-233. After checking the U-233 against their license, it was noticed that the U-233 is currently not listed on their current license. After additional review of archival records, it was found that the listing of U-233 was a remnant of their license #0032-18. License #0032-18 was terminated in 2012. The material has not been used in decades. The U-233 will stay in their radioactive materials storage vault and will not be used for any research. The plan moving forward is to eventually transfer the U-233 to a new research laboratory at the Colorado School of Mines. An amendment to current license to add U-233 is needed for this transfer."

Florida Event Number: FL23-080

CONCURRENT REPORT - FIRE DOOR MALFUNCTION

The following information was provided by the licensee via email:

"At approximately 0940 EDT on May 18th, the New Hanover County Deputy Fire Marshal was notified that the fire door of the dry conversion process (DCP) elevator shaft malfunctioned and was in the open position. The DCP elevator is located on the south wall of the DCP which is a credited fire barrier. A fire watch was initiated and maintained until the elevator door was closed at approximately 1030 EDT. The elevator was restored to full operation at approximately 1330 EDT on May 18th. Because the New Hanover County Deputy Fire Marshall was notified, a concurrent notification to the NRC Operations Center is being made per 10 CFR 70, Appendix A(c)."

The NRC region will be notified.

AGREEMENT STATE REPORT - CONTAMINATED WORKER

The following information was provided by Texas Department of State Health Services (the Department) via email:

"On May 18, 2023, The University of Texas MD Anderson Cancer Center (the licensee) reported to this Department that they had discovered a technician and package with contamination of around 12,000 dpm [disintegrations per minute]. The licensee's technician picked up the bag (package) with their bare hands. They then did a wipe test of the bag and found that it was contaminated. They also discovered that both their hands were contaminated. They washed repeatedly which reduced the contamination on their hands but did not eliminate it. The licensee believes that the remaining contamination has been absorbed into their skin and that it is no longer removable. The technician has gone home with instructions to continue wearing gloves. The technician is pregnant, and the licensee plans to perform a thyroid check tomorrow.

"The bag had elevated readings at the handle, but the contamination seemed to mostly be at the top right of the bag where the zipper handle was located. The licensee has not found contamination in any other areas of their facility. The licensee used a well counter to try to determine the isotope and believes it is either 5 microcuries of technetium-99m or 2 microcuries of iodine-123. A comparison of activities of the following day will determine which isotope it is since there is a significant difference in half-lives. The container with the ordered 10 millicuries of iodine-123, which was inside the bag, was wiped and found to not be contaminated.

"The nuclear pharmacy that supplied the bag and material inside the bag did wipe tests of the driver's hands, the steering wheel, pedals, the rack the bag would sit on, and the hand truck that the package would have been placed on. They did not find any radiation above background. They also performed wipes and surveys within their facility and again did not find any contamination.

"The worker who prepared the material at the pharmacy in the morning only drew iodine-123 for this single package. All other iodine-123 packages were pre-prepared. The pharmacy sent around 45 packages out in the morning to many medical facilities. None have reported contamination. The truck only carries packages from this single pharmacy.

"The Department has asked both facilities to continue to look for contamination and has recommended that the technician wear cotton gloves inside of the other gloves to hopefully get the hands to sweat the material out into the cotton."

Texas incident number: 10020.