Event Notification Report for July 01, 2025

AGREEMENT STATE REPORT - STOLEN GAUGE

The following report was received via email by the Virginia Radioactive Materials Program (VRMP):

"At approximately 1515 EDT on 7/2/2025, VRMP was notified of an incident involving a stolen portable nuclear gauge. Sometime between the hours of 1500 on 7/1/2025 and 0700 on 7/2/2025, a Troxler model 3411 portable nuclear density/moisture gauge containing 9 mCi Cs-137 and 44 mCi Am-241 was discovered missing from a construction site. The authorized user notified the radiation safety officer (RSO) who went to the site to search and then notified the VRMP.

"Per the RSO, at approximately 1500 on 7/1/2025, the authorized user left the gauge on the site to carry other items to his vehicle outside the fenced construction site a short distance away when it started to rain and then found the gate to the site locked when he returned to retrieve the gauge. He did not notify the RSO at that time. He returned at approximately 2030 on 7/1/2025 to find the gauge missing. He returned to the licensee's office and notified the RSO around noon on 7/2/2025. The RSO went to the site to search for the gauge. When he could not find it, he contacted the VRMP. He is also contacting the Alexandria Police Department to report the theft. The gauge was not in the transportation box when it was left on the site.

"VRMP will follow up with an investigation."

Virginia Event Report Number: VA250002

* * * UPDATE ON 07/08/2025 AT 1740 EDT FROM SHEILA NELSON TO ROBERT THOMPSON * * *

The following information was provided by the Virginia Radioactive Materials Program (VRMP) via email:

"The VRMP was notified at 1230 EDT that the missing gauge has been recovered. The gauge appears to be undamaged with no signs of tampering. The licensee will obtain a leak test and evaluate the gauge for serviceability. The agency will schedule an in-person investigation."

Notified R1DO (Bickett), NMSS Events Notification (email), 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 - LOST EXIT SIGN

The following is a summary of information received from the Colorado Department of Public Health and Environment via email:

One exit sign, containing 10 curies of tritium, was determined to be lost by the licensee.

Manufacturer: SRB Technologies
Model Number: BX-10-BK

Colorado Event Number: CO250019

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 is a summary of the information provided by the Louisiana Department of Environmental Quality (LA DEQ) via email:

The LA DEQ received notification from the licensee's radiation safety officer (RSO) that a prostate cancer patient, who was prescribed boost therapy by implantation of 83 seeds containing 1.26 mCi of Pd-103 each into the prostate, was found to have received the implantation of all seeds into the perineum instead. This was discovered by the licensee's medical physicist at approximately 1738 CST on November 4, 2025.

The improper seed implantation was detected as a result of the physicist's analysis of the post-computed tomography (CT) scan. The physicist reported the medical event without delay to the RSO. The RSO reported the medical event in accordance with Louisiana Administrative Code (LAC) 33:XV.712.B.2. at approximately 0825 CST on November 5, 2025. The RSO stated the post-CT scan had been performed on October 27, 2025, at Our Lady of the Lake Regional Medical Center (OLOL), Baton Rouge, LA. Only CT technologists had reviewed the scan on that date and the improper placement of the seeds was not detected at that time.

The seed implantation procedure was conducted at OLOL on July 1, 2025. The patient's urologist was present during the implantation procedure. The RSO stated the root cause of the medical event was still under investigation. The two root cause hypotheses are: 1) faulty zeroing of the ultrasound that the oncologist used to guide implantation of seeds into the patient's prostate due to confusion of the balloon and the patients unusually narrow pelvic arch and 2) movement on the part of the patient pushed the balloon partly out, resulting in incorrect seed implantation. No radiation dose to either the patient's bladder or rectum is suspected. The referring physician and patient will be notified of the medical event within the required 24-hour period.

Louisiana report ID number: LA2500012

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.