Event Notification Report for April 04, 2025

EN Revision Imported Date: 4/4/2025

EN Revision Text: 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).

* * * UPDATE ON 04/03/2025 AT 1033 EDT FROM ANASTASIA BENNETT TO JORDAN WINGATE * * *

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

On April 2, 2025, a phone call was made to the radiation safety officer (RSO) for further clarification. The error originated from an incorrect recording of the dose units by the nuclear technician. The misrecorded information was then relayed to RLS Radiopharmacies, resulting in a labeling discrepancy. The technician did not verify or cross-check the recorded units before confirming the prescribed dose. The licensee is working to acquire an electronic tracking system like Epic within the next two months to ensure that miscommunications are limited. The radiation safety officer submitted a follow-up email to provide further clarification.

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.

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.

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

AGREEMENT STATE REPORT - FOUND SOURCE
The following information was provided by the Texas Department of State Health Services (the Department) via phone and email:

"On March 28, 2025, the Department was contacted by the radiation safety officer (RSO) of an industrial radiography company licensed in the state of Texas. The RSO stated they were contacted by a local fire chief about a device found on the side of the road in Texas City, Texas. The RSO went to the location and identified the device as a Troxler model 3411-B moisture density gauge. The RSO stated he measured 1.4 mR/hr at the surface of the gauge. The radionuclide was identified as cesium-137. The RSO stated he transported the gauge to their facility to store it in their vault. The gauge label plate states the gauge contains an 8 millicurie cesium - 137 source and a 40 millicurie americium - 241 source. The gauge cesium operating rod was fully retracted, and a lock was in place on the cesium source operating rod. The operating rod and lock were very corroded. The storage case the gauge was contained in looked to be in very good condition. The RSO provided pictures of the gauge to the Department. The RSO also provided the serial number for the gauge. The Department searched both its local and the national Nuclear Materials Event Database and did not find a record of the gauge being reported as lost in the State of Texas. The Department contacted the RSO for the gauge manufacturer and was provided with the name of the licensee the gauge had been sold to. A search of the Department's licensing records found the license of the company who had purchased the gauge had been revoked by the Department on July 1, 1991. The Department has arranged to take possession of the gauge on Monday March 31, 2025. Additional information will be provided as it is received in accordance with SA-300."

Texas incident number: 10187
NMED number: TX250021