Event Notification Report for May 16, 2025

AGREEMENT STATE REPORT - MEDICAL EVENT

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

"The Agency was contacted on 5/16/2025 by Advocate Christ Medical Center (Oak Lawn, IL), to advise of a medical administration of Y-90 microspheres that resulted in 100% of the dose not being administered. The administration occurred earlier that day and the reporting requirements were met by the licensee. Both the patient and the referring physician were notified. Inspectors will follow up next week to gather relevant details.

"The licensee advised that a patient was to be administered 1.129 GBq of Y-90 Theraspheres on 5/16/25. The authorized user reportedly initiated the administration but noticed the radiation monitor did not decrease as the procedure continued. The manufacturer's representative was on site and began to assist with troubleshooting. Ultimately, the administration was aborted, and PET-CT scanning indicated the microspheres were unable to leave the vial. PET-CT imaging of the patient further indicated no microspheres were administered. However, as the administration had been initiated; this is being reported as an under-dose."

Illinois item number: IL250022

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.

MEDICAL EVENT

The following is a summary of information provided by the licensee via phone and email:

A patient was administered two Y-90 Therasphere treatments to the liver, each with its own written directive. The first treatment was administered without issue. The second treatment, which was a prescribed 1,382 Gy dose to the liver, resulted in no dose delivered due to a catheter malfunction. Post-administration, the activity level of the second Y-90 container was unchanged.

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 - LOST MOISTURE DENSITY GAUGE

The following information was provided by the California Department of Public Health, Radiologic Health Branch (the Department) via email:

"The Department was notified by Krazan and Associates' radiation safety officer that a Troxler model 3430 gauge (8 mCi Cs-137, 40 mCi Am-241/Be, serial number 35944) was lost from a gauge operator's vehicle in the city of El Cajon, CA. The gauge operator finished work and placed the gauge into the Troxler transit case without engaging the trigger lock on the gamma source's handle or locking the transit box latch. The transit case was left in the pickup truck bed next to the security box that is normally used during transportation.

"The gauge operator was distracted by a cell phone call and failed to return to secure the gauge and lift/secure the tailgate. The gauge operator drove the vehicle until recalling that the gauge was not secured, but it had already fallen from the truck. The operator retraced the route and eventually found the Troxler transit case on the side of the road, but the moisture density gauge, all associated tools, and paperwork from inside were missing.

"The licensee has notified local law enforcement and posted a reward on the City of El Cajon's social media page."

California event number: 051625

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 is a summary provided by the Florida Bureau of Radiation Control (BRC) via email:

The radiation safety officer (RSO) called the BRC to report a medical event involving Y-90 microspheres. The RSO stated that on 5/16/2025 it was planned for the patient to receive two administrations of 22 mCi microspheres. It was discovered on 5/20/2025 at 1730 EDT that the patient received only an administration of 3.54 mCi for the first treatment and 3.35 mCi for the second treatment. The attending physician and patient have both been notified. A report from the RSO will follow.

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.