Event Notification Report for February 26, 2025

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was received from the Massachusetts Radiation Control Program (the Agency) via email:

"On 02/14/25, at 0549 EST, the licensee, Beth Israel Deaconess Medical Center reported a medical event involving Yttrium-90 Theraspheres (Nordion BWXT ITG Canada, Inc. Model TheraSphere Y-90 Glass Microsphere System, SSD NR-0220-D-131-S). The total administered activity differed from prescribed treatment activity as documented in the written directive by 20 percent or more.

"The medical event occurred on 2/14/2025. The patient received two doses. For the first dose, the activity delivered was calculated to be 58.4 percent of the prescribed activity (prescribed activity: 1.84 GBq, delivered activity: 1.075 GBq). For the second dose, the activity delivered was calculated to be 68.6 percent of the prescribed activity (prescribed activity: 0.8 GBq, delivered activity: 0.549 GBq). The event was identified on 2/14/25. The licensee did not report if there were any adverse effects on the patient. The licensee did not report whether the authorized user, referring physician, and patient have been notified.

"The Agency will follow up with the licensee radiation safety officer to determine the event cause and corrective actions. This is the second medical event during this week involving Theraspheres from this licensee. The licensee has ceased Therasphere procedures at the facility.

"The Agency considers this event open. The Agency will follow up with a special inspection of the licensee."

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 SMOKE DETECTOR FOIL

The following information was received from the New York State Department of Health (NYSDOH) via phone and email:

"On February 18, 2025, at 1415 EST, NYSDOH received a phone call from the Chief Operating Officer of NRD, LLC to report a compromised package of returned Am-241 smoke detection foils with an activity of approximately 1 microcurie per foil. This shipment contained approximately 30,900 Am-241 foils and originated from a client in Mexico. Identifying information of the facility which sent this package is unclear.

"NRD, LLC stated that the package was discovered when one of the receiving technicians picked up the package and noticed that approximately 50 individual foils had fallen from the box onto the floor. Staff vacated the area, and shoes were surveyed to confirm that no contamination was present. A more enhanced survey was performed, and the foils appeared to be fully intact, localized to where this box had been temporarily stored, and no removable contamination was present in the receiving area or dock.

"NRD, LLC reviewed security footage and found that the package in question was transported by a common carrier and was dropped off at approximately 1035 EST on Friday, February 14, 2025. It does not appear that the package had been dropped, mishandled or manipulated upon delivery. Out of precaution, NRD, LLC surveyed the outside locations near where the common carrier driver had parked and pathway to the receiving dock and found one Am-241 foil. There was no evidence of damage or unusual mishandling on the package, however, the labeling and markings for the shipment were not easily identifiable. It is suspected that the foils were improperly packaged when originally sent from the client in Mexico, however, this cannot be confirmed at this time.

"NRD, LLC immediately quarantined the package to prevent the potential spread of contamination and placed it in a secured location within NRD, LLC's labs. NRD, LLC contacted the common carrier and the client in Mexico to inform them of the situation. NRD, LLC plans to open the package within a restricted laboratory area to minimize the potential for contamination or loss of smoke detector foils, minimize any potential dose to workers, and ensure control over environmental conditions to inventory and survey the package using personnel protective equipment.

"NYSDOH and New York State Department of Environmental Conservation (NYSDEC) are closely monitoring this event.

"NRD, LLC will be following up with NYSDOH and NYSDEC with a written report of the event and any additional information gathered.

"Given the normal activity of these sources, the loss of one Am-241 foil would meet the reporting requirements by 10 CFR 20.2201(a)(1)(i). Provided the nature of this event and the potential loss exceeding the reportability threshold, this event is being reported given the absence of validated information on the inventory. It is not suspected that there is any risk to public health or the environment from this event.

"NYSDOH is monitoring this event and has assigned NYSDOH Incident No. 1516 to internally track this event."

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

The estimated dimensions of each foil are comparable to those of a three-ring hole punch. NYSDOH considers it plausible that one or more foils may be missing.

Event Report ID No.: NY-25-03

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 - EQUIPMENT FAILURE

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

"The Agency was notified on 2/18/25, by the radiation safety officer for OSF St. Anthony in Rockford, IL of an apparent equipment failure with their high dose rate therapy unit that occurred on 2/13/25. Reportedly, the device was unable to extend the 5.33 Ci Ir-192 source, resulting in the administration being aborted. No dose was delivered to the patient. Inspectors are performing a reactive inspection tomorrow, 2/19/25."

Source: Sealed Source Brachytherapy
Serial Number: 24-01-2930-001-112224-11727-14

Illinois Item Number: IL250008

LOST CHEMICAL AGENT DETECTORS

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

On February 18, 2025, Naval Sea System Command Detachment, Radiological Affairs Support Office was notified of the following information:

On February 10, 2025, Marine Corps Logistics Command declared the loss of ten automatic chemical agent detector alarm (ACADA) systems (model no. NSN 6665-01-438-3673). Each ACADA contains 30 mCi of Ni-63. The loss was identified by the Marine Corps Logistics Command Radiological Control Office during October 2024 actions to terminate their Ni-63 permit (10-67004-T1NP). The last known reference to the detectors were during an October 2022 shipment from command distribution in Albany, GA to a force storage battalion where the detectors never arrived. Various interviews, search, and tracking efforts occurred with the detectors being removed from inventory in April 2024.

No known exposures have occurred.

To prevent recurrence, RFIDs are being utilized to ensure tracking and accountability along with adherence to GCSS-MC tracking standards.

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