Event Notification Report for May 15, 2025

AGREEMENT STATE REPORT - POTENTIAL EXTREMITY OVEREXPOSURE

The following information was provided by the Pennsylvania Department of Radiation Protection (the Department) via email:

"On May 6, 2025, and May 7, 2025, the licensee informed the Department of a possible high ring badge exposure of a nuclear medicine technologist. It is reportable per 10 CFR 20.2202(b)(1)(iii).

"On May 6, 2025, the licensee was notified by Mirion (their dosimetry provider) of a high ring badge exposure to a nuclear medicine technologist in the first quarter (Q1) of 2025. The exposure reading was 57,448 millirem, exceeding the allowable annual limit. The technologist also received a higher-than-normal dose to their whole-body badge of 405 millirem. The nuclear medicine technologist was notified about the exposure. The licensee interviewed the technologist to determine what may have caused the high reading on the ring badge. It was determined that the most likely source of the high reading was American College of Radiology phantom accreditation testing. The technologist performed the test twice in Q1 2025. The test involved injecting 15-25 mCi of Tc-99m into a water-filled phantom. The technologist does not recall injecting or handling the phantom without gloves on but thinks they must have handled the phantom without gloves and touched a small amount of contamination on the outside of the phantom. They also recall carrying the phantom from the hot lab to the camera and back, holding it to their body. This is believed to be the source of the higher-than-normal whole-body badge.

"The licensee believes that the nuclear medicine technologist may have handled the phantom without gloves on and picked up a small amount of contamination on their ring as a result.

"The Department will perform a reactive inspection. More information will be provided as received."

Pennsylvania Event Report ID: PA250007

AGREEMENT STATE REPORT - MISSING PACKAGES

The following information is a summary provided by the Illinois Emergency Management Agency (Agency) via phone and email:

On May 7th, 2025, the Agency received a notification from Bard Brachytherapy in Carol Stream, IL to advise of four missing packages of I-125.

Package A: 39 sources, activity - 1457.430 MBq (39.39 mCi)
Package B: 39 sources, activity - 1457.430 MBq (39.39 mCi)
Package C: 39 sources, activity - 1457.430 MBq (39.39 mCi)
Package D: 40 sources, activity - 1494.800 MBq (40.40 mCi)

Source model number: STM 1251

The package was sent via [common carrier] from Chicago O'Hare Airport on May 2nd, 2025. The package destination was East London, Africa.

An investigation by the Agency is ongoing.

Illinois Item Number: IL250018

* * * UPDATE ON 05/08/2025 AT 1501 EDT FROM GARY FORSEE TO JORDAN WINGATE * * *

"On May 7, 2025, Bard Brachytherapy reported to the Agency the apparent loss of (4) packages containing a total of (158) I-125 brachytherapy seeds with an activity of 0.59 mCi each. The packages were shipped to a client in South Africa via [common carrier] at Chicago O'Hare Airport on May 2, 2025. Data available at the time of the report indicated the packages had been lost while in the possession of the carrier. The following day, May 8, 2025, the licensee advised the packages had actually arrived timely in South Africa on May 4, 2025. No public exposures resulted from this incident. Pending the licensee's written report and explanation on gaps in accountability, this matter is considered closed."

Notified R3DO (Ruiz), NMSS Events Notification (email) and ILTAB (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 Kentucky Department for Public Health (the Department) via email:

"On 4/24/2025, permanent implant brachytherapy (isotope unknown at this time) was administered without a written directive. A pre-treatment plan was completed and approved by the authorized user (AU), and treatment was administered on this basis by the AU, but no pre-implant or post-implant written directives meeting the requirements of 10 CFR 35 were completed. The event was identified during the post implant dosimetry process on 5/6/2025.

"This event is under investigation. University of Kentucky has temporarily paused implants while they complete their assessment and implement corrective actions.

"The written report will follow as required in 15 days. A reactive inspection will be performed by the Department."

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 - STOLEN GAUGE

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

"On May 8, 2025, the licensee reported that at 1245 CDT a Humboldt moisture density gauge containing two sources, an 8 mCi [Cs-137] source and a 40 mCi Am-241/Be source, was stolen from a truck at a jobsite in Houston. The gauge was locked in the bed of the transport vehicle while the gauge operator was in the restroom. The chains holding the gauge were cut and the gauge removed. It was reported to the Houston police department. The licensee reported the handle was in the up position and locked and there is no immediate danger to the public.

"Additional information will be made available in accordance with SA-300 reporting requirements."

Texas NMED # 250027
Texas Incident # 10196

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