Event Notification Report for April 01, 2025

AGREEMENT STATE REPORT - MEDICAL EVENT

The following is a summary of information provided by the New York City Department of Health via email:

On February 26, 2025, the licensee reported a dose administered differed by more than 20 percent of the prescribed dose. During an administration of Lu-177-PSMA [lutetium-177-prostate specific membrane antigen], the administration was stopped because it was determined that the patient's creatine level was significantly elevated. The administered activity was estimated as 49 mCi, out of an intended/prescribed activity of 162 mCi.

New York Identification Number: NYC-25-0226.

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 MATERIAL

The following information was provided by the New York City (NYC) Department of Health via email:

"The licensee reported a loss of licensed material in quantity more than 1000 times the value in 10 CFR part 20 appendix C.

"The radiation safety officer for New York University (NYU) Langone Hospitals (NYC license number: 75-2955-01) reported on the phone that they misplaced a shipment of Lu-177 for medical use. The material was delivered yesterday morning [03/24/25], but this morning they could not locate it. They think it may have been put in the trash, and they are following up with their waste company to try to track it down. The activity was about 200 millicuries as of yesterday.

"A written report is expected with more information from the licensee."

* * * UPDATE ON 03/31/2025 AT 1317 EDT FROM ERIK FINKELSTEIN TO OSSY FONT * * *

The following summary was provided by the New York City (NYC) Department of Health via email:

The licensee located the material inside a large garbage dumpster on their property. They will be working to retrieve it.

Notified R1DO (Bickett), NMSS Events Notifications (email), ILTAB (email), and CNSC (Canada) (email).

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 provided by the Georgia Radioactive Materials Program via email:

"Licensee contact stated the following: On March 12, 2025, a 71-year-old female patient received an administration of 1.98 millicuries (mCi) of sodium iodide I-123 for nuclear medicine thyroid imaging with uptake. The standard prescribed dose for this study is approximately 200 microcuries. Initial dose calculations, based on the package insert and a measured thyroid uptake of 64.7 percent, estimate the absorbed thyroid dose to be 1.67 Gy (167 rad). These calculations assume administration occurred near the end of the drug's expiration period. Further clarification regarding the exact dosing time will assist in refining the thyroid dose assessment.

"An investigation is ongoing to determine the source of this dosing discrepancy. A formal written report will be submitted by the licensee on Friday, March 28, 2025."

GA NMED Report Incident #92

* * * UPDATE ON 03/31/2025 AT 1551 EDT FROM ANASTASIA BENNETT TO KERBY SCALES * * *

The following update is a summary of information received from the Georgia Radioactive Materials Program via email:

A patient was supposed to receive 200 microcuries of iodine-123 but instead received 1.98 mCi for a thyroid imaging study. The administered dose was approximately ten times higher than intended. This error resulted from miscommunication and mislabeling of the dose. The authorized user assessed the situation and determined that the risk of thyroid harm was minimal. The hospital calculated the thyroid dose to be approximately 1.74 Gy (174 rad) and has since implemented new safety measures. These include requiring faxed orders for radiopharmaceuticals and instituting multiple reviews for dose inspections to prevent future errors.

Notified R1DO (Bickett), NMSS Coordinator (Allen), NMSS (Silberfeld) 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