Event Notification Report for November 27, 2023

MEDICAL EVENT - Y-90 POTENTIAL UNDERDOSE

The following information was provided by the UP (Upper Peninsula) Health Systems Marquette via phone in accordance with Headquarters Operations Officers Report Guidance:

On 11/17/23 at 1100 EST at UP Health System Marquette, the radiation safety officer (RSO) determined that a patient received a dose that differed from the prescribed dose by more than 20 percent. The patient was prescribed a dose of 11.34 mCi of Y-90. The target organ was a tumor located in the patient's liver. The dose was administered to the target organ as expected, however, calculations on the remaining radioactivity left over from the administration estimated that the patient received a dose of only 2.82 mCi (24.9 percent of the prescribed dose). The RSO notified the referring physician, and the referring physician will notify the patient. The RSO is currently investigating the cause of the underdose and will submit a 15-day written report to follow up once the investigation is complete.

* * * RETRACTION ON 11/20/23 AT 1111 EST FROM BILL PYLE TO BILL GOTT * * *

The following information was provided by the UP (Upper Peninsula) Health Systems Marquette via phone:

The initial dose estimate was based on incorrect measurements and has been revaluated and the dose was in the acceptable range.

Notified R3DO (Feliz-Adorno) and NMSS Events Notification (via email).

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 - EQUIPMENT FAILURE

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

"On November 21, 2023, the licensee's radiation safety officer notified the Department that on November 20, 2023, during an intravascular brachytherapy (IVB) procedure, the strontium-90 source train did not reach the dwell position within 15 seconds. When they attempted to retract the source, it would not retract into the fully shielded position in the device, but it was outside the patient. Following established procedures, the delivery system (catheter, source train, etc.) was removed from the patient and placed in the device's emergency box. There were no overexposures to the patient or staff. The licensee used a second device and completed the IVB procedure on the patient. After a short time, the licensee was able to return the source train to the fully shielded position in the device. The manufacturer's representative will be coming onsite to perform an evaluation. The licensee did observe what appeared to be a possible kink in the catheter. More information will be provided as it is obtained in accordance with SA-300.

"Device Information: Best Vascular Novoste IVB model A1000

"Source Information: Source train of 16 strontium-90 sources, current total activity 35.9 millicuries."

Texas Incident Number: 10067

Texas NMED Number: TX230053

AGREEMENT STATE - LOST MOISTURE DENSITY GAUGE

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

"On November 21, 2023, the licensee's radiation safety officer (RSO) advised the Department that one of its technicians had lost a Humboldt 5001EZ moisture density gauge [which contains a nominal activity of 40 mCi of Am-241:Be and 10 mCi of Cs-137]. The technician had finished testing at a temporary job site and then took a phone call. After completing the call, he left the job site with the moisture density gauge sitting on the tailgate. When he realized what had happened, he called the project supervisor who sent workers out to search the testing area and surrounding areas. The technician notified the RSO and started driving back to the site while looking for the gauge. The RSO sent more technicians out to assist in the search and he also notified the local police department. The RSO reported the trigger lock was not on the insertion rod and it was only the gauge that was lost. It was not inside the transport case at the time. Search of the driving route will resume after daylight and the RSO will be checking with other construction workers at this and nearby sites. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300."

Texas Incident Number: 10069

Texas NMED Number: TX230054


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