Event Notification Report for June 16, 2025

AGREEMENT STATE REPORT - LOSS OF CONTROL OF RADIOACTIVE MATERIAL

The following is a summary of information provided by the Kentucky Department of Radiation Control (the Department) via email:

The Nelson County Emergency Management Agency reported that two blue containers were discovered in a rural location with radioactive material markings. The Department investigated and found the containers were lead pigs from August 6, 2024 which held decayed F-18 positron emission tomography doses. The containers were assayed, and no removable contamination was found on the packages. All radiation readings showed no levels above background.

The Department took custody of the materials and will investigate both the vendor listed on the package as well as the hospital. Local fire and law enforcement responded to the incident.

AGREEMENT STATE REPORT - STUCK OPEN GAUGE

The following information was provided by the South Carolina Department of Environmental Services (the Department) via phone and email:

"The licensee informed the Department via telephone on June 5, 2025, that a fixed gauging device was disabled or failed to function as designed. The licensee reported that a sealed source was stuck (exposed) in a dip tube assembly that was attached to a process vessel. The licensee reported that a representative from a licensed service provider was on-site and was able to remove the sealed source from the dip tube assembly and place the sealed source into a transport shield.

"The sealed source is a 9 millicurie cobalt-60 Berthold Technologies USA, LLC Model P2608-100.

"The licensee did not report any overexposures or ongoing health/safety concerns.

"This event is still under investigation by the Department."

South Carolina Event Report ID Number: TBD

AGREEMENT STATE REPORT - MEDICAL EVENT

The following report was received via phone and email from the South Carolina Department of Health and Environmental Control (the Department):

"The licensee informed the Department via telephone on June 6, 2025, that a medical event had occurred on June 5, 2025. The licensee reported that a Y-90 microsphere procedure resulted in 71 percent of the prescribed dose being administered to a patient (a difference of 29 percent), and that a spill also occurred during the administration. The licensee is reporting that the spill originated from the delivery system and likely caused the medical event.

"The licensee reported that the spill in the administration area was cleaned, and the area was released. The licensee is not reporting any overexposures or ongoing health or safety concerns. The referring physician was notified on June 6, 2025. This event is still under investigation 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.

South Carolina Event Report ID Number: TBD

MEDICAL EVENT

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

On June 6, 2025, a technologist injected Tc-99m Pertechnetate into the nebulizer instead of Tc-99m DTPA (diethylene-triamine-pentaacetate) for a lung perfusion ventilation study. The patient was an 11-year-old child with a weight of 61 lbs. (27.72 kg). The nuclear medicine technologist grabbed the wrong syringe and did not verify the information on the label before injecting into the nebulizer. The technologist has been advised by the physician on the need to ensure the labeling is correct prior to injection or use and to verify that it contains the correct compound for the correct study. The patient's family and the referring physician have been notified.

Initial indications of patient dose was 63.9 rem whole body (due to Tc-99m pertechnetate) with an initially prescribed activity of 18 mCi (Tc-99m DTPA) to the lungs. No indication of acute blood changes or radiation sickness. The licensee does not intend to call REAC/TS.

* * * RETRACTION ON 06/10/25 AT 1435 EDT FROM DAVID RHOE TO KERBY SCALES * * *

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

"The original dosimetry estimate has been revised and indicates no organ dose exceeds the 50 rem limit or the 5 rem effective dose. The dose that was reported as 63.9 Rem was meant to be for an organ dose and not whole body. After much assistance from the NRC staff, a revised dosimetry estimate has been performed.

"The estimate was performed using the MIRDcalc program with the dose of 18 mCi Tc-99m for a 10-year-old female."


Notified R1DO (Warnek), NMSS (Allen), and NMSS Events Notification via 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 report was received by the Pennsylvania Bureau of Radiation Protection, Department of Environmental Protection (the Department) via email:

"On June 6, 2025, the licensee informed the Department of a medical event. It is reportable as per 10 CFR 35.3045. On that day, the licensee was performing a Lu-177 dotatate procedure when it was noticed about halfway into the procedure that the pump infusion setup had a slow, obscured, and contained leak onto underlying absorbent paper. The procedure was then stopped. The prescribed dose was 200mCi and it is estimated at this time that approximately 70-90 mCi were administered. Both the referring physician and the patient were notified the same day. No overexposures were recorded. No harm is expected to the patient.

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

PA NMED Event Number: PA250010

* * * UPDATE ON 6/12/2025 AT 0934 EDT FROM JOHN CHIPPO TO ERNEST WEST * * *

The following report was received by the Pennsylvania Bureau of Radiation Protection via email:

"On June 6, 2025, the licensee was performing the second (of four) Lu-177 dotatate (Lutathera) treatments. The patient was prescribed 200 mCi of Lu-177 dotatate. A slow, obscured leak in the side port of the 3-way stopcock was discovered approximately halfway through the 30-minute administration despite the side-port being properly capped. The remaining dosage (11.4 ml of 25 ml) was slowly pushed by hand after an adjustment was made to the stopcock to stop the leak and the infusion was completed. Subsequent radiological measurements by radiation safety of the absorbent containing the leaked material and of the patient were immediately presumptive for a significant loss of material, which was confirmed by additional measurements and calculations. A medical event was declared upon finding the patient received less than 80 percent of the intended dose. It is estimated that approximately 88.4 mCi were administered. All leaked material was contained to the underlying, leakproof absorbent and the articles situated upon it; no other areas of contamination were found. Both the referring physician and the patient were notified the same day. No overexposures were recorded. No harm is expected to the patient."

Notified R1DO (Warnek), 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.