Event Notification Report for July 18, 2024

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
07/17/2024 - 07/18/2024

EVENT NUMBERS
57222 57223
Agreement State
Event Number: 57222
Rep Org: NJ Dept of Environmental Protection
Licensee: Kennedy Memorial Hospital
Region: 1
City: Cherry Hill   State: NJ
County:
License #: 454403
Agreement: Y
Docket:
NRC Notified By: Richard Peros
HQ OPS Officer: Robert A. Thompson
Notification Date: 07/10/2024
Notification Time: 16:32 [ET]
Event Date: 07/10/2024
Event Time: 00:00 [EDT]
Last Update Date: 07/10/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Henrion, Mark (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - Y-90 UNDERDOSE

The following is a summary of information provided by the New Jersey Department of Environmental Protection (NJDEP) via email:

Kennedy Memorial Hospital University Medical Center (the licensee) was scheduled to administer a Nordion TheraSphere therapy (116 mCi of Y-90) to a patient. The target organ was the right hepatic lobe of the liver. There was a tubing failure in the delivery system and the administration was suspended. It is estimated that only 2.62 mCi (17 percent) of the prescribed dosage was administered.

The patient and referring physician were notified. The patient has been re-scheduled for treatment.

No release of licensed material or contamination was reported.

The licensee will follow-up with a full written report. The licensee is sending the equipment that failed to the manufacturer for detailed analysis.


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
Event Number: 57223
Rep Org: Arizona Dept of Health Services
Licensee: ACS Engineering Group
Region: 4
City: Mesa   State: AZ
County: Maricopa
License #: 07- 422
Agreement: Y
Docket:
NRC Notified By: Brian D. Goretzki
HQ OPS Officer: Natalie Starfish
Notification Date: 07/11/2024
Notification Time: 00:24 [ET]
Event Date: 07/10/2024
Event Time: 00:00 [MST]
Last Update Date: 07/11/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Gepford, Heather (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL)
CNSNS (Mexico) (EMAIL)
Event Text
AGREEMENT STATE - LOST TROXLER GAUGE

The following is a summary of the information provided by the Arizona Department of Health Services (the Department) via email:

On July 10, 2024, a truck carrying a portable gauge was involved in a car accident. The driver was transported to the hospital. The location and the extent of damage to the gauge and truck are currently unknown. The portable gauge is a Troxler 3440, containing 8 millicuries of Cs-137 and 40 millicuries of Am-241/Be.

The Department has requested additional information and continues to investigate the event.

Arizona Incident: 24-008

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