Event Notification Report for January 21, 2025

AGREEMENT STATE REPORT - OCCUPATIONAL DOSE EXCEEDANCE (EXTREMITY)

The following is a summary of information received from the New York State Department of Health Bureau of Environmental Radiation Protection (NYSDOH) via phone and email:

NYSDOH was notified on January 22, 2025, that an interventional radiologist had exceeded the occupational dose for extremities (50 rem in a calendar year) for 2024. The radiologist routinely performs yttrium-90 microspheres and x-ray fluoroscopic procedures, and it is unclear what the primary cause is of this overexposure. The left-ring badge dosimeter for this authorized user indicated doses of 92.395 Rem for year 2024. This investigation will include the procedure(s) that have been performed to outline potential causes for these elevated extremity doses.

The licensed medical facility's radiation safety officer immediately provided a written notification to the affected authorized user and is performing a root cause analysis to further identify primary and contributing causes of this overexposure. NYSDOH is closely monitoring this event and has assigned NYSDOH incident No. 1513. More information will be provided to NMED once available.

NY event number: NY-25-01

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:

Three exit signs, each containing 10 curies of tritium (30 curies total), were determined to be lost by the licensee.

Manufacturer: Isolite Corporation
Model Number: SLX60

Colorado Event Number: CO25001


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

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was received from the Colorado Department of Health via email:

"On January 21, 2025, at 1400 MST, an authorized medical physicist for Community Hospital, reported a medical event to the Radiation Program of the Colorado Department of Public Health and Environment resulting from a yttrium-90 (Y-90) SIR-Sphere administration. The licensee reported that 78.8 percent (14.9 mCi) of the prescribed 18.9 mCi Y-90 dose was delivered to the treatment site and the remaining approximately 21.2 percent (4.4 mCi) of the prescribed dose remained in the delivery line post-procedure.

"The licensee reported and confirmed that there was no shunting or other blockage and the patient did not experience any emergent medical conditions during the treatment that would have resulted in the medical event. At the conclusion of the case, the authorized user was delivering the dose as normal and did not encounter increased pressure or stasis. The licensee confirmed through post treatment radiation area surveys that no spills had occurred and that there was no additional significant radioactive material that was not accounted for. The Colorado Radiation program is continuing to investigate this medical event."

Colorado Event Report ID Number: CO250002

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.