Event Notification Report for March 20, 2025

AGREEMENT STATE REPORT - LOST SOURCE

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

"On March 21, 2025, the Illinois Emergency Management Agency received a notification from G. E. Healthcare in Arlington Heights, IL to advise of a radiopharmaceutical package missing in transit. The package was shipped via [common carrier] on March 19, 2025, to the San Francisco International Airport (SFO) for delivery on March 20, 2025, to RLS Radiopharmacy in Sacramento, CA. The lost package contained two vials of iodine-123 DaTscan, containing 40 mCi at the time of shipment. The last documented scan shows no movement after an arrival scan at the SFO cargo station on the evening of March 19th at 2005 PDT. At this time, the [common carrier] conducted searches at both the O'Hare International and SFO airports along with ramps and gates with no developments.

"The package contents have since decayed to less than 2 mCi and do not represent a public exposure hazard. This package would be considered an IAEA Category 5 source, meaning it is the least likely to be dangerous, and even if dispersed would not cause permanent injury.

"Illinois Emergency Management Agency will be contacting California to make them aware."

Illinois Item Number: IL250015

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

EN Revision Imported Date: 4/7/2025

EN Revision Text: UNABLE TO RETRACT SOURCE

The following is a summary of information provided by Protect, LLC via phone:

At 1043 CDT on 3/21/2025, the radiography crew was unable to retract the source for a radiography camera while performing work at a customer's manufacturing facility in Joplin, MO. The crew went to retract the source into the radiography camera, but the source did not move. The crew established boundaries to limit exposure to less than 2 millirem/hr. The crew notified site personnel and is monitoring the posted boundaries until the source is secured. Additional licensee personnel are enroute to retrieve the source. No personnel exposures due to the malfunction have occurred.

Additional information:
Manufacturer and model number: QSA Global 880
Serial number: A424-9
Source: Ir-192
Activity: 13 Ci

* * * UPDATE ON 03/21/2025 AT 1712 EDT FROM MATT SLAYMAKER TO TENISHA MEADOWS * * *

The following information was provided by Protect, LLC via email:

"On 3/21/2025, Protect, LLC had an industrial radiography source disconnect incident occur while at a customer's manufacturing facility in Joplin, MO. At approximately 1043 CDT, during the crew's first source retraction, it was determined that the source had become disconnected from the drive cable. The crew immediately recognized the situation through the use of their dosimetry equipment and established the emergency 2 millirem/hr boundaries. The regional radiation safety officer (RRSO) was immediately notified of the issue. The RRSO informed the crew to maintain surveillance of the restricted area barricades and to wait until the RRSO and corporate radiation safety officer (CRSO) arrived before any further actions were taken. The CRSO and RRSO arrived at the jobsite at approximately 1340 CDT to retrieve the source. The source was secured back into the exposure device at 1404 CDT. The CRSO received 4.5 millirem during the retrieval procedure and the RRSO received 0.6 millirem.

"Additional information on the manufacturer and model number of equipment involved in the incident:
"QSA Global 880 delta exposure device
"QSA Global Ir-192 source (13 curies), model A424-9
"QSA Global 35 ft control cables
"QSA Global 7 ft extreme weather source tube with a 4 half-value layer (HVL) collimator

"All three personnel on the job are carded radiographers."

Notified R3DO (Havertape) and NMSS Events Notifications (email)

* * * UPDATE ON 04/04/2025 AT 1142 EDT FROM MATT SLAYMAKER TO ROBERT THOMPSON * * *

The following is a summary of information provided by Protect, LLC via email:

A thorough inspection of the exposure device, source pig tail and associated equipment was performed. The crank assembly failed the misconnect test but passed all of the no-go gauge checks. The extreme weather source tube showed minimal signs of wear with a slight bend on the end swaged connection. It is not exactly clear if the disconnect was caused by an operator error when the drive cable was connected to the exposure device or if somehow the source was able to become disconnected in the source tube while retracting the source back to the camera. As a precautionary measure the associated equipment was taken out of service.

A corrective action report was issued related to this incident. Notifications to all employees will be conducted in a mandatory in-person attendance safety stand down and will be documented. Safety stand downs and re-training will be completed by April 18, 2025.

Notified R3DO (Hills), NMSS Events Notifications (email).

AGREEMENT STATE REPORT- UNPLANNED CONTAMINATION AND MEDICAL EVENT

The following information was provided by the Arizona Department of Health Services (the Department) via email:

"On March 26, 2025, the Department received notification from the licensee about a medical event involving Y-90 (Eye90 [microspheres]) that occurred on March 20, 2025. The set up of the delivery device and administration of the Y-90 took approximately 20 minutes. During the delivery, it was noted that there were droplets on the microcatheter. While surveying personnel who were leaving the room, contamination on shoe covers and scrubs was found, which started the shutdown of the room to control [the spread of] contamination. Contamination was found on the delivery table, patient drapes, floor draping, shoe covers, and the lower part of the scrub pants of the physician. All of the contaminated items were collected, and the room was cleaned. In addition, a patient survey was performed, and the reading was significantly lower than expected. The patient was prescribed a dose of 1.72 GBq, but the licensee believes that the patient only received 30 - 55 percent of [the prescribed amount]. The Department has requested additional information and continues to investigate the event.

"Additional information will be provided as it is received in accordance with SA-300."

AZ Event Number: 25-006

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.