Event Notification Report for August 25, 2023

AGREEMENT STATE REPORT - LOST SOURCES MISSING IN TRANSIT

The following information was received via email and telephone by the Illinois Emergency Management Agency [the Agency]:

"The Agency was notified the afternoon of August 16, 2023 by G.E. Healthcare in Arlington Heights, IL (RML IL-01109-01) to advise of two radiopharmaceutical packages missing in transit. The last known location was the common carrier facility in Memphis, TN. The carrier informed the licensee that the packages could not be located and are now identified as missing. These packages do not represent a significant public safety hazard and there are no indications of intentional theft or diversion. Details of the packages are below:

"Package 1: Shipped on August 11, 2023 to RLS USA, Inc. Sugar Notch in Pittston, PA under tracking number 782355003930. Contained (1) 3 mL shielded vial of In-111. Package activity at the time of shipment was 5.210 mCi. Currently, 1.5 mCi at the time of this e-mail. The last scan occurred at 0035 CDT on August 12, 2023. GE Healthcare contacted the customer and confirmed that the package was not received.

"Package 2: Shipped on August 11, 2023 to Cardinal Health in Sarasota, FL under tracking number 782382357185. Contained (1) 3 mL shielded vial of In-111. Package activity at the time of shipment was 5.210 mCi. Currently, 1.512 mCi at the time of this e-mail. The last scan occurred at 0035 CDT on August 12, 2023. GE Healthcare contacted the customer and confirmed that the package was not received."

Illinois Event Number: IL230018

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.

FITNESS FOR DUTY (FFD) REPORT

The following information was provided by the licensee via email:

A non-licensed contract supervisor failed a test specified by the FFD testing program. The employee's access to the plant has been terminated.

The NRC Resident Inspectors have been notified

FITNESS FOR DUTY (FFD) REPORT - NON-LICENSED SUPERVISOR VIOLATED FFD POLICY

The following information was provided by the licensee via email:

"On August 23, 2023 at 2100 CDT, Grand Gulf Nuclear Station was notified that a non-licensed supervisor violated the station's Fitness for Duty policy. The employee's unescorted access at Grand Gulf Nuclear Station has been terminated. This event was determined to be reportable under 10 CFR 26.719(b)(2)(ii).

"The NRC Resident Inspector has been notified."