Event Notification Report for January 31, 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 - 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.

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