Event Notification Report for September 22, 2023

AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE

The following information was received from the New Jersey Department of Environmental Protection (NJDEP) via email:

"On 9/15/2023, NJDEP staff was notified of a potential overexposure of an authorized user (AU) at a radiopharmacy. This licensee states that a whole body badge from June was submitted late and results were just received. This AU's June badge results were 4632 mrem. The badge was processed twice to ensure the reading was correct. This brings the AU's annual readings to 5351 mrem. As a result, the licensee has been put on work restrictions while an investigation is done. The licensee has also requested Landauer reprocess the badge. Staff was also told that the ring badges had the exact same reading as the whole body badge. Records of instant read out dosimeters are kept by this licensee and all recorded readings were no higher than 2 mR per day for June and July. More information to follow as the licensee's investigation is completed."

New Jersey Event Number: To Be Determined

AGREEMENT STATE - PATIENT UNDERDOSE

The following information was received from the state of Illinois via email:

"During the course of a routine inspection at the licensee's facility on 9/14/23, inspectors discovered an underdose of a TheraSphere Y-90 treatment performed on 4/14/2023. A patient was receiving treatment for two different liver segments. The first TheraSphere dose to liver segment 3 was prescribed at 200 Gy and the patient only received 150 Gy (75 percent of the intended dose). A second written directive for segment two was successfully delivered (200 Gy prescribed and 194 Gy delivered). At the bottom of the segment 3 written directive an AMP [accredited medical practitioner] wrote 'Due to possible air in tubing, dose to segment 3 was slightly underdosed. Cumulative dose to both segments is 86 percent of [prescribed]'. Inspectors informed the licensee that each written directive is a stand alone document and that this would qualify as a medical event.

"On 9/15/23, the authorized user [AU] physician advised there was no adverse impact to the patient. The licensee advised the referring physician and was working to contact the patient. The AU determined the dose was medically sufficient. The licensee is aware of the 15 day reporting requirement and a written report is pending."

Illinois Item Number: IL230026

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 - STUCK SOURCE

The following information was provided by Alabama Radiation Control via email:

"The licensee's representative called an Alabama Radiation Control staff member to report that an RT [radiographic testing] crew working at Alabama River Cellulose in Perdue Hill, AL, called to advise that a radiography source could not be retracted. The call was received by the radiation control staff member at about 1715 CDT on 9/14/23. The representative did not have many details, and was preparing to leave the ATS [Applied Technical Services] office in Marietta, Georgia to respond.

"Alabama Radiation Control received a report from the licensee's representative between very late on 9/14/23, to very early on 9/15/23, that the source was able to be retracted. The representative stated that a wire in the crank was apparently damaged.

"Alabama Radiation Control will provide more information as the investigation continues."

Alabama Incident Number: To Be Determined

FITNESS-FOR-DUTY REPORT

The following information was provided by the licensee via phone and email:

"A licensed operator had a confirmed positive test for alcohol during another entity's pre-access fitness-for-duty screening for unescorted access authorization. The individual's unescorted access at Peach Bottom Atomic Power Station has been denied.

"The NRC Resident Inspector has been notified."