Event Notification Report for June 27, 2023

AGREEMENT STATE REPORT - STOLEN MOISTURE DENSITY GAUGE

The following report was received by the California Department of Public Health (the Department) via email:

"On June 19, 2023, the licensee notified the Department that at 0100 [PDT] one nuclear gauge (Troxler 3430, SN 19706) containing 8 mCi Cs-137 and 40 mCi Am-241/Be was stolen from a locked vehicle that was parked in an apartment complex. The gauge was stored in its case that was chained and locked to the pick up truck bed. The gauge was not visible as the bed of the truck was fitted with a locking cover. The cover had been broken open and the locks securing the gauge were cut. Sacramento Police were notified and an electronic report was filed.

"The Department will investigate."

California Event Number: 061923

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

AGREEMENT STATE REPORT - PATIENT UNDERDOSE

The following information was provided by the Arkansas Department of Health via email:

"On June 19, 2023, at approximately 1300 CDT, the licensee contacted the Arkansas Department of Health to report a medical event from Jefferson Regional Medical Center, Pine Bluff, Arkansas. The Radiation Safety Officer, Imaging Services Compliance Specialist, called to report a mishap with their first procedures with Y-90. It appears that their patient was to have received 19.8 Gray. However, due to equipment or patient issues the patient received only 6% (i.e. 2.6 Gray). The original injection was to have been 68.5 mCi.

"The report from the licensee is as follows: This is a termination of the Y-90 therapy due to stasis of the administration. 'Based on dosimeter readings of the Y-90 vial, and Geiger-Mueller meter measurements of the equipment, the microspheres were blocked in a tubing connector and did not fully reach the patient and/or organ. There was no spillage or contamination of microspheres from the Y-90 dose. The tubing and catheter were placed in appropriate shielding for long term decay in storage. Below and attached are the calculations we received from the lead Nuclear Medicine technologist and Therasphere representative.'

"Written Directive: 68.6 mCi

"Administration: 64.9 mCi at 1030 [CDT]

"Start: 1138 [CDT]

"Stasis Termination: 1209 [CDT]

"Dose to patient: 3.6 mCi"

AR event number: ARK-2023-004

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.