Event Notification Report for December 22, 2025

LOST STATIC ELIMINATOR

The following is a summary of information provided by SABIC via email:

SABIC reported the loss of a Nuclecel ionizer air nozzle on lease from NRD, LLC containing 10 mCi of polonium-210.

The device was noticed to be missing on December 10, 2025, when preparing to send the device back to NRD. The last known use was in May 2025.

This device was used to clean static-sensitive printed circuit boards. SABIC assumes that an employee used it and did not return it or mistook it for a general use air nozzle and it is among their tools. SABIC has searched the building and interviewed employees who would have had access to the device in their secure facility.

SABIC is discontinuing the work requiring use of the device.

Model number: P02021-8001
S/N: A2NJ342
NRD lease: 083488

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

SHUTTER FAILURE

The following is a summary of information provided by the licensee via phone:

On November 4, 2025, at 1425 EST, the licensee radiation safety officer (RSO) was performing a tagout of the facility's kiln, which contains a 150 mCi Co-60 source in a Berthold model LB7444 device. When attempting to close the device shutter, the RSO observed no confirmation of the beam being broken and assumed the shutter was not turning. The shutter is normally open. Access to the kiln was restricted. There were no unexpected exposures. Replacement parts have been ordered, and the device will be serviced in the coming week.

AGREEMENT STATE REPORT - EQUIPMENT FAILURE

The following information was provided by the Texas Department of State Health Services (the Department) via phone and email:

"On December 12, 2025, the Department was notified by the licensee radiation safety officer (RSO) that an event occurred on December 9, 2025, involving its Electra source irradiator. The RSO was not notified of the event until December 12, 2025. The event occurred when a patient was positioned for treatment. Approximately 1.5 seconds into the treatment an alarm occurred, and the irradiator automatically retracted the patient from the machine and closed the shutters on the device, shielding the sources. The technician entered the room and the dose rates appeared normal. Upon further inspection, the technician found one of the shutters had not closed. The technician closed the shutter manually. The RSO stated that after the patient was removed and the shutter manually closed the device was operated and functioned normally. The RSO stated the calculated dose to the patient was 0.7 rem. The patient was prescribed to receive a dose of 25 gray to the brain. The patient's physician was notified of the event and will notify the patient. The cause of the error has not been determined. A vendor has been contacted and will arrive to test the device on December 15, 2025. The RSO stated there will be no adverse effects to the patient from this event.

"Additional information will be provided as it is received in accordance with SA-300."

Texas incident number: 10245

MEDICAL EVENT

The following information was provided by the licensee via phone:

On December 12, 2025, at 0959 EST, a patient received a TheraSphere Y-90 microsphere treatment to the liver. After post-treatment imaging, it was determined that the duodenum received 56 Gy to a portion of the organ, or 19 Gy averaged across the entire duodenum. The target liver site had a prescribed dose of 239.8 Gy and received 238 Gy. Catheter placement was confirmed to be correct. There was no patient intervention. A physician has reviewed the event and has determined that no unintended permanent functional damage to an organ or a physiological system has occurred. 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.


* * * RETRACTION ON 12/17/25 AT 0859 EST FROM ALAN JACKSON TO KAREN COTTON * * *

The following information was provided by the licensee via phone:

After further evaluation, it was determined that the procedure meets the definition of shunting and is, therefore, not reportable. This report is being retracted.

Notified R3DO (Orlikowski) and NMSS Events Notification (email).

PACKAGE SURFACE CONTAMINATION EXCEEDS LIMIT

The following information was provided by the licensee via phone:

The licensee received three packages of Lu-177 from their vendor. One of the packages was found to have surface contamination of 82,019 dpm/300 cm^2 (273 dpm/cm^2), in excess of the 10 CFR 71.87 limit of 240 dpm/cm^2. After the licensee confirmed that the contamination was not spread to other areas, the contents were unloaded and the packaging placed in their storage area to decay.

The vendor and delivery company have been notified.

* * * RETRACTION ON 12/15/2025 AT 1208 EST FROM CAMI STILL TO ERNEST WEST * * *

The following information was provided by the licensee via phone:

Additional testing was conducted, and it was determined that the radioactivity detected was pre-existing on the wipe used to obtain a smear of the package. There was no contamination that originated from the package. Any contamination on the wipe was confined to the hot lab.

Notified R3DO (Orlikowski) and NMSS Events Notification (email)

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was provided by the PA Bureau of Radiation Protection (the Department) via email:

"On December 12, 2025, a patient was receiving a Y-90 TheraSphere treatment. The prescribed dose was 131.08 mCi. The patient received a dose of 72.4 mCi. No effect on the patient occurred.

"It is suspected that the cause was either the use of a third-party administration tubing set or a microcatheter defect, that caused a delay in administration leading to a clog in the line. The official cause is still under investigation.

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

PA event report ID number: PA250018

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.

* * * UPDATE ON 12/19/25 AT 1112 EST FROM JOHN CHIPPO TO KAREN COTTON * * *

The following additional information was provided by the PA Bureau of Radiation Protection (the Department) via email:

"On December 12, 2025, a patient was receiving 2 doses of Y-90 TheraSphere to 2 treatment sites. The prescribed dose was 131.08 mCi. The administration set was connected using the Boston Scientific checklist and all pre-checks, flushes, and priming were satisfactory with proper flow confirmed for the delivery kit and microcatheter. Issues developed as the first (larger) dose delivery initiated including leakage at the C-line, increased pressure, and excessive saline diversion to the pressure release vial. The RADOS dosimeter reduced by 93 percent, suggesting successful administration, however, subsequent 4-point measurements indicated a dose delivery of only 60.8 percent. It was determined that a 44.7 percent deviation between prescribed and administered dose occurred. The second smaller dose displayed the same issues with leakage and excess saline diversion but was administered with greater than 90 percent delivery. The patient received a dose of 72.4 mCi. The referring physician and the patient were notified. There was no adverse impact to the patient.

"It is suspected that the cause was the use of defective backup administration kits made by B. Braun, which were provided by Boston Scientific when the normal kits used at Thomas Jefferson University Hospital were unavailable due to backorder. The authorized user observed problems from the start of the administration including C-line clamp failure (requiring a hemostat to correct), increased pressure, and excess saline backflow to the pressure relief vial. An eventual obstruction occurred downstream after the dose vial and before the microcatheter, likely the clamp area between points 'D' and 'E' in the tubing. A high exposure rate was observed at this location (3.7 R/hr) while examining the waste materials supporting this location as having the obstruction. No other locations had exposure rates anywhere near this high.

"A second dose was administered to the same patient to a different treatment site in the liver using a fresh backup administration kit and the problem with the failed C-clamp and increased saline backflow repeated. In this case the dose was successfully delivered, likely because it was a much smaller dose (less beads, less chance of clumping up and obstructing the line in an environment of abnormal flow dynamics).

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

Notified R1DO (Carfang) and NMSS Events Notification (Email)