Event Notification Report for August 29, 2024

MEDICAL UNDERDOSE

The following information was provided by the Department of Veterans Affairs (VA) via email:

"VA Boston Healthcare System, Boston, Massachusetts, which holds Veterans Health Administration (VHA) Permit Number 20-00671-02 under the VA Master Materials License, reported discovery of a medical event to the National Health Physics Program (NHPP) at approximately 1410 CDT, August 20, 2024. A therapeutic administration of Y-90 microspheres (TheraSphere) to the right lobe of a patient's liver was conducted at approximately 1300 EDT on August 20, 2024. Measurements and calculations indicated the patient received about 63 percent of the prescribed activity. The prescribed activity was 42.9 mCi; the administered activity was estimated at 27 mCi. A causal analysis of the medical event is being performed by the medical center.

"The patient and the referring physician have been notified. Short term harm to the patient is not expected. NHPP plans to perform a reactive inspection to assess causes and regulatory compliance. NHPP will follow up with a written report in accordance with NRC requirements in 10 CFR 35.3045. NHPP has notified the NRC Region III Project Manager, Bryan Parker."

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 - DAMAGED GAUGE

The following summary was provided by the Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (DWMRC) via phone and email:

The licensee (IGES INGENIEROS, L.L.C. DBA GEOSTRATA) contacted the DWMRC to report that a portable gauge, Troxler 3430 model, with a 8 mCi Cs-137 and a 40 mCi Am-241/Be source, fall off the back of a truck. Once the licensee noticed the gauge was missing, they returned to the scene and found the damaged gauge. Although the gauge was in pieces, the sources were intact and there was no apparent leakage identified. Swipe tests were taken and the results are pending.

Utah event report ID number: UT 240006

UNPLANNED CONTAMINATION INVOLVING MELTING OF SOURCE

The following summary was provided by via phone:

The facility Steel of West Virginia notified the NRC (see National Response Center report #1408695 for additional notifications) to inform them that they potentially melted a Cesium-137 (Cs-137) source during their melting process before shipping scrap metal to another facility in Chicago, Illinois. Radiation detectors indicated positive readings for Cs-137 in the atmosphere at this facility. The source of the material is unknown at this time. Investigation is underway. The state of West Virginia were able to take radiation readings in the facility's bag house and readings were 550 microRem/hour.

The state of Illinois likewise notified the NRC during the discovery of the shipment of bag house dust from the West Virginia steel mill had tripped a portal alarm upon arrival in Chicago. The Cs-137 was identified in the load with the dust surveying approximately 1.7 mR/hour on contact with the truck. The shipment is planned to be returned to West Virginia under a Department of Transportation (US DOT) special permit. West Virginia program staff are on site at the steel mill and confirmed Cs-137 contamination. Early indications are that a load of scrap, received on or about August 15, 2024, contained a Cs-137 source and was melted in the mill's electric arc furnace. The mill staff surveyed QA samples from recent melts and believe that the Cs-137 volatilized as it wasn't identified in finished steel product.