Event Notification Report for April 12, 2024

EN Revision Imported Date: 6/17/2024

EN Revision Text: AGREEMENT STATE - MEDICAL UNDERDOSE

The following information was provided by the South Carolina Department of Health and Environmental Control (Department) via email:

"The South Carolina Department of Health and Environmental Control was notified via telephone at approximately 1301 [EDT] on 4/12/24, that a medical event had been discovered by the licensee on 4/12/24 at approximately 1130 [EDT]. The Medical University of South Carolina (MUSC) reports an underdose to a patient's liver during a Y-90 microsphere procedure by 78 percent of the prescribed 120 Gray (Gy) dose. The licensee estimates that the patient received 27 Gy, which is 22 percent of the intended 120 Gy dose. The licensee reports that the total dose or activity delivered differs from the prescribed dose or activity, as documented in the written directive, by 20 percent or more. The patient was notified of this medical event verbally.

"The licensee reports no immediate or ongoing concerns to public health and safety. Department inspectors will be dispatched to the facility to investigate this event. This event is still under investigation by the South Carolina Department of Health and Environmental Control."

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.


* * * UPDATE ON 04/26/2024 AT 0934 EDT FROM ADAM GAUSE TO JOSUE RAMIREZ * * *

The following update was provided by the South Carolina Department of Health and Environmental Control via email:

"The licensee has submitted a 15-day written report. This event is still under investigation by the South Carolina Department of Health and Environmental Control.

"The internal identification number for this event is SC240001."

Notified R1DO (Werkheiser), NMSS_EVENTS_NOTIFICATION via email.


* * * UPDATE ON 06/14/2024 AT 1211 EDT FROM KORINA KOCI TO ROBERT THOMPSON * * *

The following information was provided by the licensee via email:

"Department Inspectors performed an on-site investigation on 05/23/24. Details of the event were consistent with the licensee's notification and written report. The licensee attributes the root cause of the failure to administer the full dosage to the administration lines due to administration line blockage, specifically a faulty needle in the plunger of the administration kit. This event is considered closed."

Notified R1DO (Eve), NMSS_EVENTS_NOTIFICATION via email.

AGREEMENT STATE REPORT - LOST EXIT SIGNS

The following is a summary of information received from the Colorado Department of Public Health and Environment via email:

Two SRB Technologies exit signs, model number: BX10GY, containing 10 curies each, of tritium (20 curies total) were determined to be lost by the licensee.

Colorado event number CO240010


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