Event Notification Report for August 05, 2025

EN Revision Imported Date: 8/5/2025

EN Revision Text: AGREEMENT STATE REPORT - OVEREXPOSURE

The following information was provided by the Maryland Department of the Environment (MDE) via phone and email:

"On Friday, June 27, 2025, at 1249 EDT, MDE Program Manager received an email from the radiation safety officer (RSO) at Johns Hopkins University Radiation Control Unit, regarding a radiation overexposure incident involving a declared pregnant worker at the Johns Hopkins Bethesda PET facility.

"The RSO reported that a PET technician received the following radiation doses over the past three months:

"Fetal dose: 13.149 rem
"Whole body dose: 29.966 rem
"Extremity (ring) dose: 6329 rem

"Following the notification, the MDE contacted the RSO by phone to obtain additional details about the incident.

"The RSO explained that the employee's radiation exposure levels remained within acceptable limits until mid-March 2025. At that time, the technician began receiving higher-than-typical doses. The employee was informed when elevated exposure levels were initially observed in April 2025 dosimetry records.

"Upon reviewing the May 2025 dosimetry reports, the Radiation Control Office observed that the exposure levels were significantly elevated. As a result, the June 2025 dosimetry was expedited, which confirmed doses exceeding investigation thresholds. The employee was promptly notified of the dose results and was immediately removed from any work involving radioactive materials. The RSO has initiated a root cause investigation and will notify the MDE as required. This communication serves as a preliminary notification; MDE will follow up on the case and will provide further updates as appropriate."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

The overexposure was limited to one worker as two other workers' dosimetry indicate normal exposures. It is unknown at this time what radiopharmaceutical was involved or if there is an indication of spread of contamination. MDE does plan to perform a reactive inspection.

* * * UPDATE ON 6/27/2025 AT 1858 EDT FROM KRISHNAKUMAR NANGEELIL TO SAMUEL COLVARD * * *

The following summary of information was provided by the Maryland Department of the Environment (MDE) via phone and email:

The facility and license number is Johns Hopkins Imaging, Bethesda (RAML #31-314-01). The radiopharmaceuticals used contains F-18 and G-68. MDE called the facility RSO and the RSO determined that there is no indication of a spill or spread of contamination at the facility.

Notified R1DO (Arner), NMSS Events (email), NMSS (Silberfeld).

* * * UPDATE ON 8/4/2025 AT 1400 EDT FROM KRISHNAKUMAR NANGEELIL TO JON LILLIENDAHL * * *

The following summary of information was provided by the Maryland Department of the Environment via email:

Following further investigation, the facility received updated dosimetry reports from their contractor. These values were confirmed through reanalysis using multiple instruments. Based on this reassessment, the originally reported doses were found to differ slightly from the earlier reported values. Specifically, the updated fetal dose is 14.790 rem.

Notified R1DO (Henrion), NMSS Events (email), NMSS (Allen).

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was provided by the Florida Bureau of Radiation Control (BRC) via email:

"BRC was notified on 7/28/25 that on Friday, 7/25/25, a patient at Advent Health, Daytona was receiving Y-90 TheraSphere treatment for the liver. The patient received a dose which differed by more than 20 percent from the prescribed dose. Treatment was provided in 2 segments, denoted in 2 scripts. One segment received the full prescribed treatment, while the other segment received 51 percent of the intended treatment. Due to the treatment being provided as 2 scripts, treatment two differed by more than 20 percent.

"The [licensee's] radiation safety officer states that the dosimeter on the vial showed a dose of 0, but when all administration materials were removed, the residual within the equipment was much higher than expected. The primary care provider has been informed. It is unknown if the patient has been informed."

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.

DAMAGED GAUGE

The following information was provided by the licensee via phone:

On July 7, 2025, at 1550 EDT, a density technician was taking a measurement when they were struck by construction equipment. The individual was transported to the hospital for medical attention and the gauge was damaged by the construction equipment. The radiation safety officer responded to the site, pulled the gauge out of the ground, and verified that the source was still intact at the tip of the rod. The gauge was placed in a drum filled with sand and transported to a radioactive material storage facility owned by the licensee. The next morning, InstroTek was contacted to plan disposal of the gauge. There was no additional exposure to the technician or the public during the event and all radiation and contamination surveys of the site were below background levels. The damaged gauge is an InstroTek Explorer 3500 (S/N 3257) and contains 10 mCi of Cs-137 and 40 mCi of Am-241.

AGREEMENT STATE REPORT - LOST SOURCES

The following information was provided by the California Radiation Control Program via email:

"The licensee's contract physicist reported that two Cs-137 attenuation correction sources with approximate activities of 13 mCi each were missing when the licensee went to conduct an inventory in March 2025. The licensee has searched their facility but could not locate the sources."

California Report ID Number: 072825

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 / MISSING SOURCES

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

"As a result of an Agency investigation into an unresponsive general licensee, three (3) x-ray florescence analyzers containing 30 millicuries each of Am-241, are being reported as lost or missing. The quantity of radioactive material involved, while unlikely to be dangerous to the public, is immediately reportable to the Agency and the U.S. Nuclear Regulatory Commission when lost or missing. Agency staff will conduct a reactive inspection to determine if the portable analyzers are still on site or any additional information is available.

"The company, Bar Source International, LLC (d/b/a Pro Metals LLC) was operating in Rochelle, IL as recently as March 2020. At that time, the company was in possession of a Thermo Niton XLp-818 (s/n 10597), XL3p-800 (s/n 33072) and XL258006651 (s/n 96513). The company has been unresponsive to Agency requests and, according to a former employee, closed sometime on or after March 2020."

Illinois Item Number: IL2500030

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 SIGNS

The following is a summary of information provided by the Colorado Department of Public Health and Environmental (the Department) via email.

The Department received a notification from AMC Westminster Promanade 24 that two exit signs with 10 Ci of H-3 were lost in Westminster, CO.

Manufacture: Isolite Corporation
Model Number: 880-12-6.

Colorado Event Report ID Number: CO250023

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