Event Notification Report for November 28, 2025

MEDICAL EVENT

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

"A medical event occurred on November 17, 2025, at the Veterans Administration Medical Center in Lebanon, Pennsylvania. A patient was to be administered Lu-177 (Lutathera) by intravenous infusion for a neuroendocrine tumor. The written directive prescribed a dose of 200 mCi. During the administration, there was a leak from the administration apparatus onto absorbent material. It is estimated that only about half of the prescribed activity was delivered to the patient. The medical event was discovered on November 19, 2025, after reviewing post-treatment imaging.

"The referring physician and patient were notified of the medical event on November 19, 2025. No short-term harm to the patient is expected."

The NRC Region 3 project manager will be notified.

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

"On 10/30/25, the licensee was treating a patient with Y-90 microspheres to a liver lobe in 3 dosages. The first two dosages were successfully administered, but the third dosage did not deliver successfully, with essentially none of the dosage reaching the target. Instead, the majority of the dosage was retained in the administration apparatus with some having leaked out, resulting in contamination of the treatment room and treating personnel. While the licensee reported this event to RHB on 11/1/25, it was reported by email and not directed to the correct RHB sub-organization, nor was the email clear regarding the event. This resulted in the significant delay in reporting this event to the NRC.

"RHB is still investigating this event."

California 5010 Number: 110125


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.

SHIPMENT EXCEEDS SURFACE CONTAMINATION LIMITS

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

"On November 21, 2025, at 0835 CST, River Bend Station (RBS) was operating at 78 percent reactor power when the [radioactive waste] shipping department received a cask from the Waste Control Specialists disposal facility in Andrews County, TX via [a common carrier]. A smear sample was collected and exhibited surface contamination above the Department of Transportation (DOT) limits, specified in 49 CFR 173. The carrier was notified at 1713 CST.

"The surface contamination exceeded 24,000 [disintegrations per minute per centimeter squared] for beta gamma [activity].

"Supervision was immediately contacted and placed the shipment into a radiological controlled area.

"An investigation was performed to the extent of the condition of the loose surface contamination of the cask to determine if it was isolated to the immediately accessible areas of the cask due to an installed rain cover. The investigation concluded that the condition was extended to the surface of the cask where the average surface area exceeded DOT limits.

"This condition is immediately reportable to the NRC headquarters operations center per 10 CFR 20.1906(d)(1)."

TECHNICAL SPECIFICATION ABNORMAL OCCURRENCE

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

"On November 26, 2025, during a review of past flux trap loadings, it was identified that during the period from July 22, 2024, through August 4, 2024, the University of Missouri Research Reactor (MURR) exceeded the requirements of Technical Specification (TS) 3.8, 'Experiments.' Specifically, TS 3.8.b requires that 'The absolute value of the reactivity worth of all experiments in the center test hole shall be limited to 0.006 delta-k/k.' A review of the center test hole flux trap loading for those two weeks determined that the reactivity worth of experiments exceeded the 0.006 delta-k/k and has been re-estimated to have been approximately between 0.0061 and 0.0063 delta-k/k (from initial estimates of 0.0046 and 0.0048 delta-k/k). This underestimation of flux trap worth occurred due to inadequate programmatic controls applied to TS 4.8, 'Experiments,' specification b, which requires that 'The reactivity worth of an experiment shall be estimated or measured, as appropriate, before reactor operation with said experiment.' Specifically, multiple center test hole flux trap irradiation samples were run in the reactor without adequate prior reactivity worth estimation or measurement.

"As corrective actions to this issue, MURR is performing additional sample measurements and revising the process used for measuring and determining flux trap irradiation samples to prevent this issue from recurring.

"While the TS 3.8.b limitation is 0.006 delta-k/k, the analytical limit of the supporting safety analysis is 0.007 delta-k/k. This limitation is based upon the step insertion limits evaluated within the MURR Safety Analysis Report, Chapter 13. As a result, exceeding the 0.006 delta-k/k TS limitation by less than 0.001 delta-k/k does not result in an impact to reactor safety.

"This error does not impact any current operation or flux trap loading. This issue is being reported under TS 6.6.c(1) as it meets the TS 1.1.b and TS 1.1.f definitions for an abnormal occurrence. Specifically, TS 1.1.b defines an abnormal occurrence as an 'Operation in violation of limiting conditions for operations established in Section 3.0,' and TS 1.1.f defines abnormal occurrence as 'An observed inadequacy in the implementation of an administrative or procedural controls such that the inadequacy causes or could have caused the existence or development of an unsafe condition involving operation of the reactor.'"

The NRC Project Manager has been informed.