Event Notification Report for January 30, 2025

DAMAGED I-125 SEED

The following is a summary of information provided by the licensee via phone and email:

On January 10, 2025, two seeds were removed from a patient and placed in a safe in pathology. On January 14, 2025, a nuclear medicine technologist, retrieved the seeds from the safe for check-in with nuclear medicine. When checking in the used seeds the technologist noticed one of the seeds was shorter in length than the other. A seed evaluation was performed and comparisons revealed that seeds were different in size and that the shorter seed appeared to be hollow.

The pathology assistant ceased working and pulled excisions from the patient. Access to the workspace area was restricted. After surveying all tissue samples, only one tissue sample was determined to be radioactive. The radioactive tissue was then immediately placed in a locked box in pathology. The cutting workspace area was surveyed and determined not to be contaminated.

A medical health physicist consultant from Ohio Medical Physics Consulting (OMPC) was contacted for further direction.

A radiation safety officer (RSO) was called but was not in the office at the time. Therefore, a medical physicist took the call. The entire work area and the personnel in pathology were re-surveyed. After the second set of surveys was completed, all surfaces, floors, and previous instruments used in cutting the samples were all determined to be background. All trash and biohazard material in the pathology lab was surveyed. All surveyed material read background. The compactor and biohazard storage room were surveyed and resulted in background readings. Surgery and the cold room, where the samples were stored prior to coming to pathology, were also surveyed. The room and storage area measured background.

A radiologist was consulted regarding the imaging that was taken at the time of surgery. He stated specimen radiograph demonstrates the coil clip and the I-125 seed as well as the circular clip. The I-125 seed associated with the axillary clip was not imaged.

The imaging director and RSO were then notified of the events.

The RSO then requested to have the tissue and any items the tissue had come in contact within pathology surveyed. The specimen was determined to be radioactive along with blocks and slides the sample was placed on. A total of 9 blocks and 4 slides were determined to be contaminated. All items were placed in a lockbox. After which another area survey was completed including the pathologist's microscope, tissue processor, embedding center, microtome, and stainer. All equipment measured background. Wipe tests were also completed and measured background.

The seed and the contaminated blocks and slides will be stored in the nuclear medicine hot lab until it is deemed safe to dispose of properly.


The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

The I-125 seed contained an estimated activity of 269 microcuries.

AGREEMENT STATE REPORT - LOST RADIOACTIVE MATERIAL

The following is summary of information received from the Georgia Radioactive Materials Program Environmental Protection Division (EPD) via email:

On January 20, 2025, the licensee reported to EPD that during the closure of their location in Lawrenceville, GA sources were lost in transit back to the manufacturer. Many sealed sources were shipped by this locations staff in multiple shipments to E and Z for disposal. One shipment contained 2 packages under one [contract carrier] tracking number, and one of these packages contained the Co-60 vial. This shipment was cancelled and returned to CVG Physicians Group, LLC by the [contact carrier] due to improper labeling, but only one package was returned.

The licensee radiation safety officer (RSO) discovered the loss months later on November 21, 2024, when reviewing documentation for a radioactive material license amendment request to remove this location as a location of use. The RSO noticed a closeout survey performed by West Physics that reported the sealed sources were transferred to a radioactive materials license which the RSO was not familiar with. Further investigation showed this was not accurate, and most sources were sent back to E and Z. Reviewing the return receipts sent by E and Z, the RSO discovered seven sources could not be accounted for. Of these sources, the Co-60 source was the only missing source with a high enough activity to be a reportable event.

The licensee has searched the location and contacted other locations on the license to make sure that the sources were not transferred to those locations. The sources were not transferred and were no longer on site. The [common carrier] has been contacted and has not been able to locate the lost package. The source was shipped inside a shielded lead pig labeled as radioactive within a box. It is unlikely that any occupational worker or member of the public received any significant exposure. All staff involved in the incident have received training. EPD staff is investigating further and will update as new information becomes available.


Georgia Incident Number: 90

Isotope: Co-60
Activity: 53 microcuries (12/1/2018)
Manufacturer: E and Z
Serial Number: 2029-29-3

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.

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 - MEDICAL EVENT

The following information was provided by the licensee via email:

"As part of the MaineHealth annual physics review of the nuclear medicine program, the radiation safety officer discovered a written directive for an I-131 administration where the prescribed activity was 15 mCi and the administered activity was 18 mCi. They reported this as a medical event under Maine rules, part G.3045.A(1)(a)(ii) because the total dosage delivered differed by 20 percent from the prescribed dosage (10 CFR 35.3045(a)(1)(i)). The full report is pending, 15 days to NMED."

Maine Event Report Number: ME 25-001

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.

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN

The following information was provided by the licensee via phone or email:

"On January 28, 2025 at 0832 EST, a technical specification (TS) required shutdown was initiated at Catawba Unit 1. TS action 3.4.13, condition 'B', was entered on January 28, 2025 at 0430 when operators detected a 1.4 gpm unidentified reactor coolant system leak. TS action 3.4.13, condition 'B' has a 'required action' to reduce leakage to within limits within 4 hours. This 'required action' was not completed within the completion time; therefore, a TS required shutdown was initiated per TS 3.4.13 condition 'C'.

"This event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b)(2)(i) for `the initiation of any nuclear plant shutdown required by the plant's technical specifications.'

"There was no impact on the health and safety of the public or plant personnel. The NRC Resident Inspector has been notified."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

Based on elevated temperature readings on the pressurizer cavity in their lower containment, the licensee anticipates that the leak is in that location. The investigation is ongoing and they will ascertain more information when they reach Mode 3 and enter containment.

In addition, all safety systems are operable for Unit 1. Unit 2 was unaffected.

AGREEMENT STATE REPORT - STUCK OPEN SHUTTER

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

"On January 24, 2025, the Department was notified by the licensee that on January 23, 2025, the shutter on two Vega model SH-F2B gauges were found stuck in the open position during routine testing. Both gauges contain a 200 millicurie (original activity) cesium-137 source. The licensee reported there is no risk of additional radiation exposure to members of the general public or radiation workers due to this mechanism failure. The licensee is in the process of scheduling a source holder service contractor to evaluate and attempt repairs to the source holders. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: I-10157
Texas NMED Number: TX250004

AGREEMENT STATE REPORT - STUCK OPEN SHUTTER

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

"On January 24, 2025, the Department was notified by the licensee that on January 23, 2025, the shutters on two Vega model SH-F2B, and one Vega model SH-F2 gauges failed in the open position during routine testing. Both SH-F2B gauges contain a 300 millicurie (original activity) cesium-137 source. The Vega SH-F2 gauge contains a 3 millicurie (original activity) cesium-137 source. The licensee reported there is no risk of additional radiation exposure to members of the general public or radiation workers due to this mechanism failure. The licensee is in the process of scheduling a source holder service contractor to evaluate and attempt repairs to the source holders. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: I-10158
Texas NMED Number: TX250005

AGREEMENT STATE REPORT - STUCK OPEN SHUTTER

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

"On January 24, 2025, the Department was notified by the licensee that on January 24, 2025, the shutter on a Vega model SH-F2 gauge failed in the open position during routine testing. The gauge contains a 500 millicurie (original activity) cesium-137 source. The licensee reported there is no risk of additional radiation exposure to members of the general public or radiation workers due to this mechanism failure. The licensee is in the process of scheduling a source holder service contractor to evaluate and attempt repairs to the source holders. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: I-10159
Texas NMED Number: TX250006

MEDICAL EVENT

The following is a summary of the information provided by the licensee via phone:

On January 24, 2025, at approximately 1000 MST, a 33.9 mCi Tc-99 cardiac stress test was administered to the wrong individual. The radiation safety officer reported that the effective dose equivalent and risk of functional damage to the patient were still being determined.

The patient has been notified. This incident is under investigation.

* * * RETRACTION ON 01/24/25 AT 2004 EST FROM MICHAEL HART TO JOSUE RAMIREZ * * *

After further investigation, the radiation safety officer determined that this incident did not meet reportability criteria.

Notified R4DO (Deese), NMSS (Allen), and NMSS Events Notification (email).

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 - LOST THEN FOUND RADIOACTIVE MATERIAL SHIPMENT

The following information was provided by the New Jersey Department of Environmental Protection via email:

"Advanced Accelerator Applications (AAA) in Millburn, New Jersey, reported that a shipment of Lu-177 radiopharmaceutical was lost and subsequently recovered en route to another AAA facility in Indianapolis. The package was found on the side of the road near the Pittsburgh airport. A common carrier driver noticed it and called the police, who then called a local hazmat team to make sure it was safe. The hazmat team subsequently called the Chemical Transportation Emergency Center (CHEMTREC), who proceeded to give it to another common carrier at the Pittsburgh airport because they thought they were the courier by mistake. CHEMTREC notified AAA, who confirmed the package as their own, and sent one of their couriers to retrieve it. The courier returned the shipment back to AAA's facility in Millburn."

The activity of the Lu-177 was not provided in the initial report, but it was identified as being less than IAEA category 2.

New Jersey Incident Number: C933984