Event Notification Report for February 13, 2024

MEDICAL EVENT - DOSE MISADMINISTRATION

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

At 1110 EST on February 14, 2024, a patient was administered the wrong radiopharmaceutical. The prescribed dose was 25 mCi Tc-99m pyrophosphate, and the administered dose was 25 mCi Tc-99m sestamibi. The patient and referring physician were informed. There were no adverse effects to the patient. The total effective dose equivalent for this study was estimated to be 1,200 mrem.

* * * RETRACTION ON 2/15/24 AT 1240 EDT FROM GLADYS KAGAOAN TO ADAM KOZIOL * * *

After further review, the dose to the patient was below reporting threshold. The radiopharmaceutical was a diagnostic tracer and non-therapeutic.

Notified R1DO (Bickett), NMSS (Rivera-Capella), and 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 - SHUTTER STUCK OPEN

The following is a summary of information provided by the New Mexico Radiation Control Bureau via email:

On February 14, 2024, a routine inspection discovered that a densitometer (Berthold LB8010, serial number 10377, 20 mCi of cesium-137) was missing the handle that actuates the shutter. The shutter was in the open position. The radiation safety officer packed the defective densitometer in lead pending disposal. There were no excessive exposures due to this event.

AGREEMENT STATE REPORT - STOLEN PORTABLE GAUGE

The following was received from the Colorado Department of Public Health and Environment (the Department) via email:

"On February 14, 2024, the radiation safety officer of CTL/Thompson, Inc. reported a stolen InstroTek model 3500 series portable moisture/density gauge (Serial Number 4764). The gauge user reported they loaded the gauge at their Pueblo office and stopped at their residence to retrieve their wallet. Upon returning to their truck, both chains that secured the gauge and transportation case were cut and the gauge and transportation case were stolen. The gauge contained a 10 mCi cesium-137 source (Serial Number BG1770) and a 40 mCi americium-241: beryllium source (K147/22).The licensee was instructed to file a police report. The Department is waiting for additional details regarding the event."

CO Event Number: CO240003

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

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

The following is a synopsis of information provided by the licensee via email:

On February 13, 2024, a non-licensed supervisor violated the station's FFD policy. The employee's access at Sequoyah Nuclear Plant has been terminated.

The NRC resident inspector has been notified.

OFFSITE NOTIFICATION
The following information was provided by the licensee email:

"At 1227 CST on February 14, 2024, OSHA was notified per 29 CFR 1904.39(a)(2) that an individual was transported to an offsite medical facility for treatment that required the individual to be admitted to the hospital. The individual was not working in a radiologically control area when the injury occurred.

"This event is being reported pursuant to 10 CFR 50.72(b)(2)(xi).

"The NRC Regional Inspector has been notified of this event."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

The injured individual was working in an office environment prior to needing medical treatment.