Event Notification Report for April 02, 2025

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

UNANALYZED CONDITION

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

"The facility is in a safe and stable configuration and no accident has occurred. A non-conservative value was found in a calculation used to model the foam tank connected to the liquid effluent collection and treatment system (LECTS) slab tank. There is no immediate concern to criticality safety and additional conservatism exists in the calculation. The LECTS system was secured and signs were posted on the doors to prevent personnel from entering the room."

NRC Regional office will be notified.

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

The LECTS and foam tanks are currently empty and are normally empty tanks.

AGREEMENT STATE REPORT - LOST SOURCE

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

"NYSDOH received a phone report of a missing source on March 25, 2025, from PharmaLogic Holdings, Corp.'s corporate radiation safety officer. An email with additional details was received shortly after the phone report at approximately [1700] EDT.

"On March 3, 2025, a Co-57 flood source (activity: 15 mCi on 10/20/23 decayed to 4.19 mCi or 155 MBq on 03/03/25, manufacturer: RadQual, serial number: BM01L152326102) was shipped from Pharmalogic in Syracuse, NY to International Isotopes in Idaho Falls, ID. The package was shipped by [common carrier] on 3/03/25, with a specific tracking number.

"The package measured 29 by 19 by 4 inches and weighed 23 pounds at the time of shipment. A package with the same tracking number arrived at the destination in Idaho on 3/25/25, however, the dimensions were different than the original package and the yellow-II label on the package indicated it contained a Cs-137 source with an activity of 1.45 GBq (approximately 39 mCi). There is also a label on the package that indicates the package was being shipped to and from Technical Resources Group, Inc., in Idaho Falls, ID.

"The NYSDOH is tracking this event under incident number 1525. NYSDOH will provide an update to this notification once additional information is available."

NYSDOH is reporting per 10 CFR 20.2201(a)(1)(ii) for the theft or loss of licensed material in a quantity greater than 10 times the Appendix C value of 100 microcuries.

Event Report ID No.: NY-25-05

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 New Jersey Department of Environmental Protection via email:

"On 3/26/25, a patient at Robert Wood Johnson University Hospital was underdosed by approximately 50 percent when the Y-90 Therasphere delivery kit malfunctioned. The tubing will be kept and sent to Boston Scientific [manufacturer] for further information.

"The target organ was the liver."

NJ Event Report ID number: To be determined.

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- 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.

FAILED FITNESS FOR DUTY TEST
The following information was provided by the licensee via phone and email:

"At 1513 EDT on March 31, 2025, it was determined that a contract supervisor failed a test specified by the fitness-for-duty testing program. The individual's authorization for site access has been terminated.

"The NRC Resident Inspector has been notified."