Event Notification Report for April 24, 2025

AGREEMENT STATE REPORT - FAILED SHUTTER

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

"On April 15, 2025, the Department was notified by the licensee that the shutter on a Kay Ray 7063 gauge had failed in the open position. Open is the normal position for the gauge. The gauge contains a 200 mCi (original activity) cesium-137 source. The licensee reported that there is no risk of additional radiation exposure to members of the general public or radiation workers.

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

Texas incident number: 10192

Texas NMED number: TX250024

AGREEMENT STATE REPORT - MEDICAL EVENT

The following report was received by the California Radiation Control Program via email:

"On April 15, 2025, the radiation safety officer at Cedars Sinai Medical Center contacted Los Angeles County Public Health Radiation Management (part of the California Radiation Control Program), first by telephone at 0955 PDT and then by email at 1055 PDT, to report a medical event that occurred at Cedars Sinai Medical Center. During the administration of Y-90 TheraSpheres to a patient, the Y-90 TheraSpheres became obstructed within the intravenous tubing such that the authorized user was unable to administer the full dosage. The activity in the syringe was approximately 35 mCi, but only 12.14 mCi was delivered to the target organ. This was 35 percent of the prescribed activity. Additionally, the prescribed dose to the liver (the target organ) was 78.8 gray [7,880 rads]. The liver received a dose of 27.6 gray [2,760 rads], a difference of 51.2 gray [5,120 rads].

"A site visit by the principal radiation protection specialist, Los Angeles County Public Health Radiation Management is scheduled for April 17, 2025."

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.

California 5010 Number: 041525

MEDICAL EVENT

The following information was provided by the licensee's radiation safety officer (RSO) via phone:

During an audit performed on 04/16/2025, it was discovered, that on 01/24/2025, a patient had received a dose to the liver that was greater than 20 percent of the prescribed dose. The prescribed activity was 24.3 mCi of Y-90 microsphere, an equivalent dose of 21.95 grays to the liver. The spreadsheet containing the activity verification incorrectly listed the activity as 26.9 mCi. The actual activity administered to the patient was 29.8 mCi, an equivalent dose of 26.9 grays, which is 22.6 percent (4.95 grays) greater than the prescribed dose to the liver. The RSO intends to contact the patient and doctor.

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 report was received by the Pennsylvania Bureau of Radiation Protection [the Department] via email:

"On April 16, 2025, a patient was receiving an iridium-192 treatment using an Elekta, Inc. microSelectron HDR [high-dose radiation] [remote afterloader]. During the procedure, a software error that retracted the source occurred. The unit was rebooted, and the treatment was restarted. However, 17 seconds into restarting, the unit failed to show the next dwell position, so the treatment was terminated. Approximately 48 percent of the prescribed dose was administered to the patient. No harm is expected to the patient and both the physician and patient were notified. The patient treatment plan will be updated accordingly.

"The official cause is still under investigation. The service engineer will be onsite April 17, 2025, to troubleshoot the HDR. The Department will perform a reactive inspection. More information will be provided as received."

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.

Pennsylvania Event Report Number: PA250004

FITNESS FOR DUTY REPORT

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

"A non-licensed supervisor had a confirmed positive fitness-for-duty follow-up test. The employee's unescorted access has been terminated. This report is being made pursuant to 10 CFR 26.719(b)(2)(ii).

"The NRC Resident Inspector has been notified."

EN Revision Imported Date: 4/23/2025

EN Revision Text: OFFSITE NOTIFICATION

The following information was provided by the licensee via phone:

On April 22, 2025, at 1803 EDT, a forest fire reached the Oyster Creek property. The station contacted local fire department and the Lacey Township police department for response. At approximately 1940 EDT, the fire within the property was extinguished. The fire company continued to monitor the fire outside the property boundary at the time of this notification. There was no radiological or fuel storage damage from this event.

The NRC Regional Inspector will be notified.

EN Revision Imported Date: 4/24/2025

EN Revision Text: OFFSITE NOTIFICATION

The following is a summary of information provided by San Onofre Nuclear Generating Station (SONGS) via phone and email:

At 1554 PDT on 4/23/25, SONGS was notified of mineral oil spills that occurred in two separate locations from one transformer being delivered to SONGS. A total of 10-25 gallons of oil leaked. One leak location was on site and has been cleaned up. The second location was on state park property and has been isolated with absorbent material put down. A remediation company will remove the affected soil from the second location. The transformer has been drained and removed from the site. This report is being submitted due to offsite notifications to the San Diego Department of Environmental Health and the California Office of Emergency Services.

The NRC regional office has been notified.