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Event Notification Report for October 24, 2024

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
10/23/2024 - 10/24/2024

EVENT NUMBERS
57385 57386 57388
Agreement State
Event Number: 57385
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Rush University Medical Center
Region: 3
City: Chicago   State: IL
County:
License #: IL-01766-01
Agreement: Y
Docket:
NRC Notified By: Whitney Cox
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 10/16/2024
Notification Time: 13:06 [ET]
Event Date: 10/14/2024
Event Time: 00:00 [CDT]
Last Update Date: 10/16/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Orlikowski, Robert (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following information was provided by the Illinois Emergency Management Agency (The Agency) via phone and email:

"The Agency was contacted by the radiation safety officer (RSO) for Rush University Medical Center, on October 15, 2024, to report that a patient prescribed 66.67 mCi (479 Gy) of Y-90 Theraspheres on October 14, 2024, received only 20.14 mCi (144.7 Gy) of the prescribed dose. The patient has been notified and the RSO is still attempting to notify the referring physician who left on vacation immediately after the procedure. There was no reported adverse impact on the patient and the licensee is still discussing possible retreatment. The administering physician reported significant resistance during the administration and filling of the overflow vial. An investigation remains ongoing. The underdose (69.8 percent deviation between the prescribed and administered dose) meets the criteria as a reportable incident under 32 Illinois administrative code 335.1080. Inspectors will perform a reactive inspection on October 17, 2024."

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: 57386
Rep Org: Texas Dept of State Health Services
Licensee: Rone Engineering Services
Region: 4
City: Fort Worth   State: TX
County:
License #: L 02356
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Natalie Starfish
Notification Date: 10/16/2024
Notification Time: 16:37 [ET]
Event Date: 10/16/2024
Event Time: 00:00 [CDT]
Last Update Date: 10/17/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Taylor, Nick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - DAMAGED MOISTURE DENSITY GAUGE

The following report was received from the Texas Department of State Health Services (the Department) via phone and email:

"On October 16, 2024, the Department was notified by the licensee's radiation safety officer (RSO) that one of his technicians had lost and recovered a Troxler 3430 moisture density gauge. The gauge contains a 40 millicurie americium - 241 : beryllium source and an 8 millicurie cesium - 137 source.

"The RSO reported the technician had placed the gauge on the tail gate of their pickup truck in its transport case. The technician was in the cab of the truck waiting for their assistant to show up. The technician was notified that the trainee was not coming so he left the office parking lot. After a short distance, the technician heard a bump, looked in the rearview mirror, and saw that the tailgate was down. The road they were on was one-way, so they had to go down the road to make a U-turn. The RSO stated the technician made two passes in the area where they believed the gauge came off the truck but did not find the gauge. They then contacted their RSO and informed him of the event. The RSO instructed the technician to continue looking for the gauge. The technician found the gauge about one mile from where they started on the side of the road in a grassy ditch. The gauge was not in its [transport] case and the technician did not find the [transport] case.

"The technician recovered the gauge and took it to the licensee's office. The gauge case was damaged, but the sources remained shielded. The cesium source rod was locked in the fully shielded position.
"The RSO contacted a service company who came to the licensee's location and performed radiation surveys and a leak test on the gauge. The RSO reported radiation levels were reported to them as normal, and the leak test results for both sources were reported as less than 0.005 microcuries.

"The service company took the gauge to its location to inspect the damage to the gauge. Additional information will be provided as it is received in accordance with SA-300."

Texas NMED # TX240037


Agreement State
Event Number: 57388
Rep Org: Texas Dept of State Health Services
Licensee: East Texas Testing Laboratory, Inc.
Region: 4
City: Fort Worth   State: TX
County:
License #: L01423
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Sam Colvard
Notification Date: 10/17/2024
Notification Time: 12:02 [ET]
Event Date: 10/17/2024
Event Time: 05:45 [CDT]
Last Update Date: 10/17/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Taylor, Nick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
CNSNS (Mexico), - (EMAIL) (EMAIL)
Event Text
AGREEMENT STATE REPORT - STOLEN NUCLEAR GAUGE

The following information was provided by the Texas Department of State Health Services (the Department) via phone and email:

"On October 17, 2024, the Department was notified by the licensee's radiation safety officer (RSO) that a Troxler model 3440 gauge had been stolen from the back of one of the company's pickup trucks. The gauge contains a 40 millicurie americium-241:beryllium source and an 8 millicurie cesium-137 source. The RSO stated the technician went to the truck at 0545 CDT this morning and found that the chains holding the gauge in the truck had been cut and the gauge and transport case were missing. The RSO stated that because the gauge had not been used this day, the cesium source rod should have been locked in the fully shielded position. The City of Fort Worth's police department was notified of the theft. The RSO is traveling to the office where the gauge was normally stored to interview the technician involved in the event.
"Additional information will be provided as it is received in accordance with SA-300."

Texas NMED #: TX240039
Texas Incident #: 10138

* * * UPDATE ON 10/17/2024 AT 1435 EDT FROM ART TUCKER TO NATALIE STARFISH * * *
"The Department has sent a notice of this event to the City of Fort Worth Emergency Management Office."

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