Event Notification Report for March 11, 2025

EN Revision Imported Date: 3/11/2025

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT

The following is a summary of information provided by the State of Florida, Bureau of Radiation Control (the BRC) via email:

"[BRC was notified of a medical event involving a high dose rate (HDR) prostate treatment that] occurred on 2/25/25, was identified during the weekend of 3/1/25 to 3/2/25, and was determined to have been a medical event by the facility on 3/3/25. During [delivery of] the second fraction of two fractions, Comprehensive Hematology Oncology incorrectly typed the catheter length into the procedure's software. This resulted in the dose being received 5 cm short of the intended location. The prostate received no dose during this fraction, and the rectum received an estimated 60 percent of its expected dose. The patient and primary physician have been notified. The second fraction has been rescheduled."

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

The prescribed dose for the second fraction of the HDR prostate treatment was unknown at the time of the notification. This event is similar but involved a different patient than EN 57581 (FL25-019).

Florida Incident Number: FL25-018

* * * UPDATE ON 03/04/2025 AT 0847 EST FROM MONROE COOPER TO ROBERT THOMPSON * * *

Current information, retrieved by BRC, states that the intended total dose was 2700 cGy delivered over two fractions.

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.

EN Revision Imported Date: 3/11/2025

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT

The following is a summary of information provided by the State of Florida, Bureau of Radiation Control (the BRC) via email:

"[BRC was notified of a medical event involving a high dose rate (HDR) prostate treatment that] occurred on 2/25/25, was identified during the weekend of 3/1/25 to 3/2/25, and was determined to have been a medical event by the facility on 3/3/25. During [delivery of] the second fraction of two fractions, Comprehensive Hematology Oncology incorrectly typed the catheter length into the procedure's software. This resulted in the dose being received 5 cm short of the intended location. The prostate received no dose during this fraction, and the rectum received an estimated 60 percent of its expected dose. The patient and primary physician have been notified. The second fraction has been rescheduled."

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

The prescribed dose for the second fraction of the HDR prostate treatment was unknown at the time of the notification. This event is similar but involved a different patient than EN 57580 (FL25-018).

Florida Incident Number: FL25-019

* * * UPDATE ON 03/04/2025 AT 0847 EST FROM MONROE COOPER TO ROBERT THOMPSON * * *

Current information, retrieved by BRC, states that the intended total dose was 2700 cGy delivered over two fractions.

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 - MEDICAL EVENT

The following information was provided by the California Department of Public Health, Radiologic Health Branch, via email:

"On February 28, 2025, the radiation safety officer (RSO) at Keck Hospital of University of Southern California, contacted the Los Angeles County Radiation Management office to report a possible medical event that occurred on February 27, 2025, during a Y-90 Therasphere radioembolization treatment of a liver cancer patient. The RSO indicated that due to abnormally high readings from the waste container associated with one of two dosage vials, he was unable to confirm the dosage administered to the patient. He sent the waste container to the vendor, Boston Scientific, for evaluation, in order to determine the administered dosage.

"On March 3, 2025, [the RSO] reported via e-mail that the patient was prescribed a total dose of 1300 Gy, but only 695.5 Gy was delivered during the treatment, which was attributed to the dosage from one of two dosage vials being stuck in the tubing. The underdosage meets the criteria for a reportable medical event. The incident did not cause any harm to the patient. Further analysis will be conducted by Boston Scientific to determine the reason for the dosage being stuck in the tubing."

CA Event Number: 022825

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 MOISTURE DENSITY GUAGE

The following information was provided by the Florida Bureau of Radiation Control (BRC) via email:

"The BRC received notification from Central Florida Testing Laboratories at 1500 EST 03/04/2025 of a missing Troxler soil moisture density gauge (8 mCi Cs-137, 40 mCi Am-241/Be). The transporter was returning to the storage location from a worksite when they were notified by another driver at a stoplight that something fell out of the vehicle. When [the transporter] turned around to see what had fallen, they noticed the gauge was no longer in the back of the vehicle. [The transporter] retraced their steps, returning to the worksite, and could not locate the gauge. The last confirmed possession of the gauge was at approximately 1030 EST on 03/04/2025."

Florida incident number: FL25-021

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