Event Notification Report for February 01, 2024

AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) email:

"On February 1, 2024, a patient was receiving a lutetium-177 (Lutathera) treatment. The written directive, signed by the authorized user (AU), was for 200 mCi of Lu-177. However, the treating medical oncologist signed a 100 mCi dose alteration treatment plan order on the same day as the procedure. The patient received the 200 mCi dose that was recorded in the written directive instead of what was intended. It is believed that miscommunication occurred between the two, and a full investigation into the cause of the event is underway by the licensee. The AU and the patient have been notified. No harmful effects are expected to patient. The Department will update this event as soon as more information is provided."

PA NMED Event Number: PA240005

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.

EN Revision Imported Date: 3/1/2024

EN Revision Text: OFFSITE NOTIFICATION - WORKPLACE INJURY

The following information was provided by the licensee via email:

"On February 1, 2024, a contract worker was transported offsite for medical treatment due to a work-related injury that required the individual to be admitted to the hospital. The individual was free-released from the site prior to transport.

"The injury and hospitalization were reported by the contract worker's employer to OSHA per 29 CFR 1904.39(a)(2). Based upon that notification to another government agency, Tennessee Valley Authority is reporting this per 10 CFR 50.72(b)(2)(xi).

"The NRC Senior Resident Inspector has been notified of this event."

* * * RETRACTION ON 2/29/24 AT 12:29 EST FROM MATTHEW SLOUKA TO KAREN COTTON * * *

The following information was provided by the licensee via email:

The purpose of this notification is to retract a previous Event Notification, EN 56941, reported on 02/01/2024.

"On 02/01/2024, at 15:32 EST, Browns Ferry Nuclear Plant (BFN) made an Event Notification 56941 notifying the NRC of a notification to another government agency. During further review of NRC reporting guidance, BFN has concluded that the contract worker's employer report to OSHA was below the reporting threshold outlined in NUREG 1022, Revision 3.

"The NRC Resident Inspector has been notified."

AGREEMENT STATE REPORT - POTENTIALLY DAMAGED GAUGE

The following information was provided by the Colorado Department of Public Health and Environment (the Division) via email:

"On Thursday February 1, 2024, at approximately 1030 MST, the Division was notified of a vehicle collision that resulted in the damage of a portable nuclear gauge (Nuclear Gauge - Troxler 3430 SN: 28355).

"The initial report indicated the Type A package containing the nuclear gauge was thrown from the vehicle and both the package and the gauge sustained damage.

"Colorado State Patrol responded to the scene and determined the nuclear gauge was intact, and it was turned over to the licensee.

"The Department confirmed with the licensee the gauge was able to be secured with the source in the shielded position and the shielding for the sources is not compromised. A leak test is being expedited at this time."

Colorado Event Number: CO 240001

MEDICAL EVENT - OVERDOSE

The following is a summary of information provided by the licensee via phone:

A patient received a Y-90 Therasphere injection to the liver. The procedure was successfully completed with no abnormalities noted. After the procedure, an imaging study was conducted on the patient's liver, and it was determined that the Theraspheres had concentrated in a single segment of the liver (segment 4) when they had been expected to distribute throughout the entire liver. The calculated dose to the single segment would have exceeded the prescribed dose (633 Gy vice 91 Gy) due to the higher concentration of Y-90. The physician and patient were notified. No adverse effect is expected to the patient or the target organ.

* * * RETRACTION ON 2/8/24 AT 1547 EDT FROM VRINDA NARAYANA TO BILL GOTT * * *

After further review, the correct target was irradiated, the correct activity was injected and all procedures were followed. The average dose to the target matched the written directive. Thus, the event was not reportable, and the licensee is retracting the event.

Notified R3DO (Ziolkowski), NMSS Events (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 - LOST SOURCE

The following is a summary of information received from the Georgia Radioactive Material Program (the Department) via email:

The licensee's Assistant Director of Radiation Safety contacted the Department on February 1, 2024, at 1700 EST, to report a missing source. He stated he was notified that morning that a germanium-68 Phantom, for use with a PET/MRI (positron emission tomography/magnetic resonance imaging) machine was reported missing. It has a reference activity of 55 MBq / 1.5mCi. During a follow up call from the Department, the Assistant Director stated the source was delivered and accounted for Monday, January 29, 2024, then reported missing February 1, 2024. The source was in a restricted area and locked in the hot lab. The Assistant Director stated they have created a police report and are awaiting surveillance footage. The licensee believes it may have been thrown away accidentally, therefore they are also searching their dumpsters.

Georgia Incident Number: 77

* * * UPDATE ON 02/06/24 AT 1428 EST FROM STACY ALLMAN TO NATALIE STARFISH * * *

The following is a summary of information received from the Georgia Radioactive Material Program (the Department) via email:

The Assistant Director of Radiation Safety contacted the Department on 02/02/24 to provide an update on the steps being taken to find the lost source. They had informed the police department and opened an investigation. Security was also assisting in the investigation. The radiopharmacy that supports Emory University, called on 02/05/24 and reported their driver accidentally removed the source. The source was returned on 02/05/24 and the Assistant Director of Radiation Safety completed the check in and the leak test on the source.

Notified R1DO (Lilliendahl), NMSS Events Notification, and ILTAB via email.

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