Event Notification Report for August 25, 2025
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/24/2025 - 08/25/2025
Agreement State
Event Number: 57897
Rep Org: Arizona Dept of Health Services
Licensee: Banner University Medical Center
Region: 4
City: Tucson State: AZ
County:
License #: 10-044
Agreement: Y
Docket:
NRC Notified By: Brian Goretzki
HQ OPS Officer: Robert A. Thompson
Licensee: Banner University Medical Center
Region: 4
City: Tucson State: AZ
County:
License #: 10-044
Agreement: Y
Docket:
NRC Notified By: Brian Goretzki
HQ OPS Officer: Robert A. Thompson
Notification Date: 09/04/2025
Notification Time: 01:58 [ET]
Event Date: 08/25/2025
Event Time: 00:00 [MST]
Last Update Date: 09/04/2025
Notification Time: 01:58 [ET]
Event Date: 08/25/2025
Event Time: 00:00 [MST]
Last Update Date: 09/04/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Roldan-Otero, Lizette (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Einberg, Christian (NMSS)
Roldan-Otero, Lizette (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Einberg, Christian (NMSS)
AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was provided by the Arizona Department of Health Services (the Department) via email:
"On September 3, 2025, the Department received notification from the licensee about a medical event involving a high dose rate treatment that occurred on August 25, 2025. The event was discovered on September 2, 2025, when the patient returned for a subsequent [fractional treatment]."
"A written directive was created to deliver 4,000 cGy over 8 fractions to a scalp lesion with a 30 mm Valencia skin applicator. [A patient treatment simulation was conducted] on August 20, 2025, where the radiation therapist constructed a brain mask for immobilization that included an opening at the top of the head. This was done to allow placement of the skin applicator. On August 25, 2025, the authorized user identified a lesion that was superior to the lesion he had intended to treat, which was not biopsied. The wrong site was treated with 500 cGy by a 7.54 Ci Ir-192 source. The Department has requested additional information and continues to investigate the event."
AZ Incident Number: 25-016
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.
The following information was provided by the Arizona Department of Health Services (the Department) via email:
"On September 3, 2025, the Department received notification from the licensee about a medical event involving a high dose rate treatment that occurred on August 25, 2025. The event was discovered on September 2, 2025, when the patient returned for a subsequent [fractional treatment]."
"A written directive was created to deliver 4,000 cGy over 8 fractions to a scalp lesion with a 30 mm Valencia skin applicator. [A patient treatment simulation was conducted] on August 20, 2025, where the radiation therapist constructed a brain mask for immobilization that included an opening at the top of the head. This was done to allow placement of the skin applicator. On August 25, 2025, the authorized user identified a lesion that was superior to the lesion he had intended to treat, which was not biopsied. The wrong site was treated with 500 cGy by a 7.54 Ci Ir-192 source. The Department has requested additional information and continues to investigate the event."
AZ Incident Number: 25-016
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.
Non-Agreement State
Event Number: 57940
Rep Org: Cardinal Health
Licensee: Cardinal Health
Region: 1
City: Memphis State: TN
County:
License #: 34-31473-03MD
Agreement: Y
Docket:
NRC Notified By: Cami Still
HQ OPS Officer: Ian Howard
Licensee: Cardinal Health
Region: 1
City: Memphis State: TN
County:
License #: 34-31473-03MD
Agreement: Y
Docket:
NRC Notified By: Cami Still
HQ OPS Officer: Ian Howard
Notification Date: 09/22/2025
Notification Time: 12:45 [ET]
Event Date: 08/25/2025
Event Time: 13:53 [EDT]
Last Update Date: 09/24/2025
Notification Time: 12:45 [ET]
Event Date: 08/25/2025
Event Time: 13:53 [EDT]
Last Update Date: 09/24/2025
Emergency Class: Non Emergency
10 CFR Section:
20.2201(a)(1)(ii) - Lost/Stolen LNM>10x
10 CFR Section:
20.2201(a)(1)(ii) - Lost/Stolen LNM>10x
Person (Organization):
Lilliendahl, Jon (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Szwarc, Dariusz (R3DO)
Lilliendahl, Jon (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ILTAB, (EMAIL) (EMAIL)
Szwarc, Dariusz (R3DO)
LOST SOURCE
The following information was provided by the licensee via phone and email:
"This loss of material report is prepared per 10 CFR 20.2201(a)(1)(ii) for a loss of material of a Ra-223 dichloride (Xofigo) radiopharmaceutical package that was lost on 8/25/2025, by a [common carrier]. The package left the facility of RAM license 34-31473-03MD at 1353 EDT on 8/25/2025, to be sent to a customer location in Lincoln, NE. The package was sent through [the common carrier] in Memphis, TN, where it was declared lost on 9/3/2025. The package contained one vial of Ra-223 dichloride with a total activity at time of shipment of 92.8 microcuries. The shipment was planned to arrive in Lincoln, NE, by 1200 MST on 8/27/2025."
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
The following information was provided by the licensee via phone and email:
"This loss of material report is prepared per 10 CFR 20.2201(a)(1)(ii) for a loss of material of a Ra-223 dichloride (Xofigo) radiopharmaceutical package that was lost on 8/25/2025, by a [common carrier]. The package left the facility of RAM license 34-31473-03MD at 1353 EDT on 8/25/2025, to be sent to a customer location in Lincoln, NE. The package was sent through [the common carrier] in Memphis, TN, where it was declared lost on 9/3/2025. The package contained one vial of Ra-223 dichloride with a total activity at time of shipment of 92.8 microcuries. The shipment was planned to arrive in Lincoln, NE, by 1200 MST on 8/27/2025."
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