Event Notification Report for November 22, 2023

DOSE GREATER THAN PRESCRIBED

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

"On 11/14/2023, a patient arrived in the nuclear medicine department for administration of their fourth cycle of Lutathera, a Lu-177 labeled radiopharmaceutical. The standard prescription of Lutathera for patients is 200 mCi in accordance with manufacturer's instructions for use and industry standard. The technologist assayed the vial and went through pre-administration procedures including a pre-treatment time out. 202 mCi of Lutathera was administered via IV in the right upper forearm over the course of thirty minutes. Start time of 1211 [EST] with an end time of 1241.

"Upon completion of the procedure, the technologist noticed that the patient had been prescribed a reduced activity of 150 mCi as opposed to the standard prescription of 200 mCi. Realizing this was a medical event, the technologist notified the radiation safety officer (RSO) at approximately 1330. The technologist also informed the nuclear medicine department supervisor. The RSO proceeded to inform the Authorized User (AU)/prescribing physician.

"The AU spoke with the patient explaining that the activity administered exceeded the prescribed amount. The physician explained that he did not expect any adverse effects from the higher than prescribed activity as the patient had received the standard activity of 200 mCi. The reduced activity of 150 mCi had been decided by the prescribing physician due to borderline renal function and the patient had tolerated all previous three administrations. Since the patient's renal function was not affected by the three previous administrations, the prescribing physician explained that the patient could have received the 200 mCi. The patient did not express concern upon being informed of this event.

"The AU also informed the referring physician.

"An initial report was made to [Florida] via telephone at 1529 in accordance with 64E-5.345(4)(a)."

Florida Incident Number: FL23-164

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 - DOOR INTERLOCK FAILURE

The following information was provided by the Wisconsin Department of Health Services (the Department) email:

"On Wednesday, November 8, 2023, the licensee was treating an individual in their high dose rate (HDR) suite. During the treatment, while the Ir-192 source was exposed, it was noticed that the door to the suite was ajar. The treatment was immediately paused, and the physicist confirmed that the door was open and that the door interlock was not functioning as required. The staff closed the door, put up caution tape, and maintained constant visual surveillance to ensure no one entered. Treatment was reinitiated and completed according to the written directive.

"On Friday, November 10, 2023, the interlock had not yet been repaired, and the licensee performed another HDR treatment utilizing caution tape and constant surveillance.

"The licensee reported the event to the Department by phone on November 14, 2023.

"The licensee performed an event reconstruction and surveyed at the open door with the Ir-192 source exposed. The highest dose rate of 0.3 mR/hr indicates that no member of the public would have received a dose exceeding public dose limits from this event.

"The patients were unaffected.

"The Department will be performing a reactive inspection on November 20, 2023."

WI Event Report ID Number: WI230022

AGREEMENT STATE - LOST TROXLER GAUGE

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

"On November 15, 2023, the Department was notified by the licensee that a Troxler model 3440 moisture/density gauge had been lost. The gauge contains one 8 millicurie Cs-137 source and one 40 millicurie Am-241 source.

"The radiation safety officer (RSO) stated that on November 14, 2023, a licensee technician was performing work at a temporary job site where testing was being performed periodically. While sitting in their truck with the gauge on the tailgate of the truck, the technician realized they needed to go to a second job site about 20 minutes from where he was. When they reached the second job site, the technician realized they had left the gauge on the tailgate.

"The technician notified the licensee's RSO and the licensee conducted multiple searches for the gauge but did not locate the gauge. The RSO was advised to contact local law enforcement about the event. The RSO was advised to check local pawn shops and internet sites such as eBay and Craig's List to watch for the gauge. The RSO does not believe the gauge possesses an exposure risk to any individual. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: 10066

NMED Number: TX230052

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

HPCI DECLARED INOPERABLE

The following information was provided by the licensee via email:

"At 0956 [CST] on November 20, 2023, accumulated gas was identified in the Dresden Unit 2 high pressure coolant injection (HPCI) system discharge header. As a result, the HPCI system was declared inoperable. Since HPCI is a single-train system, this is a condition that could have prevented the fulfillment of a safety function; therefore, this condition is being reported as an eight-hour, non-emergency notification per 10 CFR 50.72(b)(3)(v)(D). The HPCI system was subsequently vented, and the accumulated gas has been removed, restoring the Dresden Unit 2 HPCI system to an operable status. All other emergency core cooling systems remained operable during this time period.

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The licensee administratively verified the isolation condenser was operable after declaring HPCI inoperable as required by technical specifications. The licensee stated there was no increase in plant risk. The cause of gas accumulating in the Dresden Unit 2 HPCI discharge header is under investigation, and this issue has been entered into the licensee's corrective action program.