Event Notification Report for April 03, 2025

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.

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was received by the Ohio Department of Health via email:

"A patient was scheduled to receive 200 mCi of PLUVICTO [Lu-177], however, they only received approximately 130 mCi [administered to the prostate]. The injection was through a three-way stopcock; one port was for the saline solution, the other for the PLUVICTO. Near the end of the injection, the material back flowed into the syringe and leaked onto the chucks under the patient's arm.

"Based on surveys of the syringe and chucks, approximately 70 mCi had leaked which resulted in a 35 percent underdose. The patient was surveyed and there was no indication the patient's skin was contaminated or signs of extravasation.

"The patient's physician was notified of the event.

"An investigation by Ohio is pending."

NMED Report Number: OH250003

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 - IMPROPER SHIPMENT OF BYPRODUCT MATERIALS

The following information was provided by the Texas Department of State Health Services (the Department) via phone and email:

"On March 6, 2025, the Department was contacted by Customs and Border Protection regarding a shipment that was passing through their checkpoint in the port of Houston, Texas. The shipment set off their radiation monitors and the radionuclides were identified as americium-241 and radium-226. When the Department contacted the shipper, the shipper stated that part of the shipment was smoke detectors. The shipper made arrangements for the shipment to be returned to the originating location in Farmers Branch, Texas. On March 14, 2025, a Department investigator went to the shipper's location and confirmed that the shipment contained two boxes with smoke detectors. On March 27, 2025, a Department investigator went back to the location to inspect the materials and perform radiological surveys. The investigator verified that the two boxes contained approximately 3,200 smoke detectors. The investigator noted that a large number of the americium-241 sources had been separated from the smoke detectors and were laying free inside the boxes. The investigator found that the dose rates on contact with the outside of the box were around 75 uR/hr. A gamma spectroscopy reading of the box determined the radionuclides to be americium-241 and radium-226. The investigator did not detect any loose surface contamination. The owner (shipper) of the package was directed to secure the packages containing the smoke detectors in a secure location. Based on the radiological surveys performed by the Department, no individual would have received a significant exposure as a result of this event. The owner of the material has agreed to impound all the sources and secure them in an area not easily accessible to an individual. The Department will assist the owner of the smoke detectors in finding a contractor to properly dispose of the material."

Texas incident number: 10185
NMED number: TX250020

There was no indication that any foils were separated from the shipping packages. The owner of the shipment does not have a Texas license for the possession of byproduct materials. The Department will continue to investigate this incident.

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."