Event Notification Report for July 06, 2023

AGREEMENT STATE - STUCK SHUTTER

The following information was provided by the Louisiana Department of Environmental Quality (the Department) via email:

"On June 28, 2023, Dow Chemical Company notified the Department that a fixed gauge had a stuck shutter in the open position. Vega Model SHF2B serial number: 0368CR with a 500 mCi Cs-137, source serial number: N/A.

"The facility was using BBP Sales to perform their six-month audit on the gauges. BBP Sales sprayed penetrating lubricant on the shutter which loosened the shutter. They plan to come back to re-spray the shutter and make sure that it functions as designed."

LA Event Report Number: LA20230009

MEDICAL EVENT - PATIENT UNDERDOSE

The following information was provided by the Veterans Health Administration (VHA) National Health Physics Program (NHPP) via phone and email:

"On June 28, 2023, the VHA NHPP was notified of a medical event at the Michael E. DeBakey VA Medical Center, Houston, Texas. The medical center holds VHA permit number 42-00084-06.

"The medical event occurred on June 28, 2023. The event involved the intra-arterial administration of two vials of yttrium-90 (Y-90) microspheres to the liver of a patient. Measurements taken after the procedure of one of the vials, the administration set, and catheter showed an unusually large amount of activity remaining that had not been delivered to the patient. From the measurements, it was estimated that only 28 percent of the prescribed activity for that vial was delivered to the patient. The activity delivered from the other vial was within regulatory requirements. The causes are not certain at this time; the event is under investigation. The patient has been notified. NHPP plans to conduct a reactive inspection regarding the event.

"NHPP will send a written report to NRC Region III in accordance with 10 CFR 35.3045. NHPP has notified the NRC Project Manager for the Master Materials License of NRC Region III."

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 - SOURCE DISCONNECT

The following was provided by the Texas Department of State Health Services (the Agency):

"On June 29, 2023, the Agency was notified by the licensee's radiation safety officer (RSO) that a source disconnect had occurred on June 28, 2023, at a temporary job site. The device (camera) was a SPEC 150 exposure device containing a 43 curie Iridium-192 source. The radiographers had placed the exposure device on an I-beam 15-feet above the floor to shoot a pipe. The device was raised to the pipe using a person lift. After the last shoot, the radiographer removed the guide tube and placed the guide tube and camera in the person lift with them. The radiographer stated they had performed a survey as they approached the camera and said the reading was bouncing up and down. The radiographer stopped halfway up and verified the crank-out indicated that the source was retracted. The radiographer removed the camera and guide tube and lowered them to the floor. Both radiographers noted their self-reading dosimeters were off scale. The radiographers contacted the RSO who had them set up a 2 millirem boundary and a qualified individual then retrieved the source. The source and camera were returned to the licensee's storage location. The radiographers' badges were sent for processing. On June 29, 2023, the RSO reported both radiographers' badges read less than 100 millirem. Additional information has been requested and will be provided as it is received in accordance with SA-300."

Texas Incident No.: 10031
Texas NMED No.: TX230029