Event Notification Report for July 28, 2023

AGREEMENT STATE REPORT - LOST SHIPMENT

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

"On August 9, 2023, the Department was notified by a licensee of radioactive material lost in shipment. The material was 1.82 GBq (49 mCi) of Y-90 Theraspheres which is greater than 1000 times the Appendix C value for Y-90 (10 microcuries). The owner of the material is the manufacturer of the microspheres. The manufacturer ships the material to the Texas licensee who is located near a major airline hub. The Texas licensee then stores the material until the owner sends an order for rapid shipping to a medical facility. At which point, the Texas licensee ships the material via a common carrier to the address on the order. The manufacturer is responsible for confirming the facility receiving the package has a radioactive material license.

"On July 27, 2023 the Texas licensee received an order from the manufacturer to ship four sets of Theraspheres to a licensee in Florida. The four sets were each in separate type A packages. The Texas licensee has closed circuit television of the common carrier picking up the four packages which were sent 'Priority Overnight'. On July 28, 2023, three of the packages arrived at the Florida licensee. The Texas licensee contacted the common carrier asking about the fourth package which has a tracking number of [deleted]. After some investigation, the common carrier reported that the package had not left their Irving, TX facility near the Dallas Fort Worth airport. Three of the packages had scans leaving that facility but not the fourth and missing package. A transit facility in Greensboro, NC reported that they did not have the package. They reported scanning three packages on the way to the Florida licensee.

"On August 3, 2023, the common carrier advised the Texas licensee that they had closed the lost claim and were no longer looking for the package.

"The Department has asked the Texas licensee to contact the dangerous goods section of the common carrier and request their assistance. This Department has also notified the Florida Radiation Control program of the incident. This Department is waiting for contact information for the radiation safety officer of the manufacturer and owner of the material. Once obtained the Department will notify the appropriate state agency. Further information will be provided per SA-300."

Texas Incident number: 10045
Texas NMED number TX230037

This event was also reported by the State of Florida under EN 56671.

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 - TREATMENT TO WRONG SIDE OF ORGAN

The following report was received via email by the Ohio Bureau of Radiation Protection:

"On July 28, 2023, a patient was scheduled to receive treatment to the right lobe of the liver, however, imaging performed on August 16, 2023 showed the left lobe received the dose. Approximately 83 mCi of Y-90 was delivered, resulting in a dose of 130 cGy (130 Rad) to the wrong treatment site. The patient and referring physician were notified. Future treatment of the left lobe of the liver was planned, but not under this written directive."

Ohio Event Number: OH230009

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.