Event Notification Report for April 13, 2026

EN Revision Imported Date: 4/13/2026

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT

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

"On March 31, 2026, the licensee informed the Department of a medical event involving an administration of a dose to the wrong individual. It is reportable as per 10 CFR 35.3045(a)(1)(ii)(c).

"On March 31, 2026, a patient was scheduled to receive Tc-99m sestamibi. The nuclear medicine technologist accidentally administered 1 mCi of I-131 that was intended for another patient. Details are still incoming at this time. The patient and referring physician have been notified. The dose to the patient is currently being calculated. We will provide more information as soon as provided.

"The Department will perform a reactive inspection."


* * * UPDATE ON 04/11/2026 AT 0742 EDT FROM JOHN CHIPPO TO JOSUE RAMIREZ * * *

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

"On March 31, 2026, a nuclear medicine technologist (NMT) was scheduled to treat two patients: Patient A was scheduled for a Tc-99m sestamibi dose for a parathyroid test; patient B was scheduled for a diagnostic dose using 1 mCi I-131 NaI. The NMT picked up the paperwork for patient B's I-131 dosing but accidentally called patient A's name. The NMT explained the exam and went over the written directive and consent paperwork with patient A. Patient A then signed the written directive and consent for treatment, even though all the paperwork had patient B's name on it. At approximately 1115 EDT, the NMT incorrectly dosed patient A with the I-131 pill that was meant for patient B. Upon making copies of the documents to give to the patient, the NMT realized his mistake and then notified the patient, his supervisor and radiation safety. Upon review of the event by the authorized user physician (AU), he chose to continue patient A with the originally scheduled Tc-99m sestamibi dosing and associated imaging, after which the patient left the hospital. Radiation safety estimated the effective dose to patient A as 84.77 rem and the thyroid dose at 165.46 rem.
"The direct cause of this event was human error, combined with deviation from policy for proper patient identification. However, during the investigation, other deviations were discovered. When the written directive for the 1 mCi of I-131 was reviewed by radiation safety, it was observed that the written directive had not been signed in advance of the treatment, as is required in accordance with 10 CFR 35.40.
"All nuclear medicine supervisors will provide a documented review of University of Pittsburgh Medical Center patient identification protocols to all NMT's across their licenses. This review will also include NMT's who support radiation oncology at this location.
"On Thursday April 2nd, the radiation safety officer also stopped all verbal approvals of written directives. This was communicated via email to nuclear medicine AUs and supervisors under the license.
"The nuclear medicine supervisor attempted to bring the patient back in for follow-up scanning to determine an accurate radiation dose for the patient. This patient declined. Follow-up bloodwork was ordered by the AU, at the request of the radiation safety officer.
"The protocol for diagnostic doses of I-131 requiring written directives was reviewed. While stating that a written directive is required, the protocol does not explicitly state that the AU needs to sign in advance of the treatment. This document will be revised to explicitly state the written directive must be signed in advance of any administration.
"The Department will perform a reactive inspection."

Notified R1DO (Dentel), NMSS (Einberg), and NMSS Events Notification (Email).


PA event report ID number: PA260005

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 South Carolina Department of Environmental Services (the Department) via phone and email:

"The South Carolina Department of Environmental Services was notified via telephone at approximately 0730 EDT on April 3, 2026, that a medical event had been discovered by the licensee on April 2, 2026, at approximately 1400 EDT. The Medical University of South Carolina (MUSC) reported an underdose to a patient's liver during a Y-90 microsphere procedure by 76 percent of the prescribed 550 Gy dose. The licensee estimates that the patient received 132.7 Gy, which is 24 percent of the intended 550 Gy dose. The licensee reports the total dose or activity delivered differs from the prescribed dose or activity, as documented in the written directive, by 20 percent or more. The patient was notified of this medical event verbally.

"The licensee reports no immediate or ongoing concerns to public health and safety. Department inspectors will be dispatched to the facility to investigate this event. This event is still under investigation by the South Carolina Department of Environmental Services."

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.

LOST SOURCE

The following information was provided by the licensee via phone:

In 2023, an Agilent gas chromatograph had its source (15 mCi Ni-63) removed and was sent for recycling. The source was placed in storage on-site. In March 2026, the licensee began returning all stored material to the manufacturer for disposal. It was determined that the stored source contained no radioactive material and the Ni-63 could not be located. After performing multiple searches, the source was deemed lost at 1445 EDT on April 2, 2026. The licensee continues its search.

* * * UPDATE ON 04/03/2026 AT 1328 EDT FROM SHANE ROGERS TO SAMUEL COLVARD * * *

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

During an August 2025 NRC license-renewal inspection, one Ni-63 source (15 mCi) was believed to have been located but not fully confirmed. A researcher later identified the equipment to which the source originally belonged. In March 2026, efforts began to dispose of or return three stored Ni-63 sources, with responsibilities transitioning between staff members as disposal and return procedures were initiated.

On April 2, 2026, staff reported that one Ni-63 source (sealed source serial U28862, detector serial U28862, sealed source model NER-004P, detector model G2397-65505) was missing from the locked storage cabinet. It was noted that the gas chromatograph from which the source had been removed had been sent for recycling several years earlier, and there was concern that the source may have been inadvertently sent with the equipment. Barcode information for the equipment was located and forwarded to support confirmation of its recycling history.

On April 3, 2026, it was verified that the gas chromatograph had been sent for recycling in August 2023 to a commercial recycling facility. A full inspection of the locked storage cabinet confirmed the missing source was not present, although certification paperwork was found. An access review indicated that while many individuals had access to the laboratory space, access to the locked cabinet was restricted to authorized personnel only. The recycling company reported that any radioactive source found in received equipment would normally be returned. The recycling company also stated that equipment from the organization is typically stripped prior to arrival and that any remaining material is transferred to another facility in a different state.

Notified R1DO (Bicket), NMSS Events Notifications (email), and 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 - STUCK SHUTTER

The following information was provided by the Illinois Emergency Management Agency and Office of Homeland Security (the Agency) via email:

"On April 3, 2026, the Agency was notified by the radiation safety officer (RSO) at Nouryon Surface Chemistry, LLC (IL-01445-01), to advise of a fixed gauge with a stuck shutter in the open position. The issue was discovered on April 2, 2026, during a routine 6-month maintenance check/inventory on the following Ronan nuclear gauge: 3M Model 4F6S (S/N M2377) Cs-137 (300 mCi as of June 1988). The RSO reported that the source normally operates in the open position and does not pose a risk to the public or employees in its current state. Surveys were conducted and readings were as expected. Repair of the stuck shutter is scheduled to occur on April 7, 2026, by the manufacturer, Ronan Engineering Company (77-00141-01). An inspector will be on site that day to conduct a reactive inspection."

Illinois Item Number: IL260010

AGREEMENT STATE REPORT - POSSIBLE OVEREXPOSURE

The following information was provided by the Tennessee Division of Radiological Health (the Department) via phone:

The Department was notified on April 3, 2026, at 1504 EDT, of a minor skin contamination event that took place at one of Precision Nuclear's radiopharmacy facilities, resulting in a possible overexposure. The employee's clothing, personal badge (dosimeter), and skin were contaminated with less than 1 mCi of flourine-18. Decontamination efforts began immediately after the event and were completed on the same day. Since the employee's badge was contaminated, final dose estimates have not been determined. The contaminated badge readings for lens dose equivalent and shallow dose were greater than the limit, however, finger ring dosimeter readings were less than the limits.

The contaminated badge readings were as follows:
Deep dose: 2,715 mrem
Shallow dose: 77,354 mrem (greater than the limit of 50,000 mrem)
Lens dose equivalent: 30,628 mrem (greater than the limit of 15,000 mrem)

Finger ring dosimeter readings were as follows:
Right finger ring: 9,902 mrem
Left finger ring: 2,066 mrem

This event is being reported to the NRC per Tennessee regulation 0400-20-05-.141 (24-hr report). The Department intends to conduct an investigation.

Tennessee Event Report ID Number: TBD

TECHNICAL SPECIFICATION VIOLATION

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

"On April 9, 2026, at approximately 1230 CDT, upon reviewing operator requalification data, Missouri University of Science and Technology Reactor (MSTR) staff determined that a licensed reactor operator did not have a current medical evaluation as required by 10 CFR 55.21. A follow-up examination was due no later than March 21, 2026. The operator was suspended from further operations until compliance with 10 CFR 55.21 was restored. However, in reviewing operations since the lapsed medical evaluation, it was determined that this operator performed licensed duties over eight shifts while out of compliance.

"Upon review with facility staff, it was determined that during approximately 75 percent of the licensed duties, at least one additional licensed operator was present in the control room for record keeping and instrumentation monitoring to support planned transients and facility evolutions. However, during the remaining operations when other licensed personnel were not present, the facility deviated from 10 CFR 50.54(k), which requires the presence of a licensed operator at the controls or, under 10 CFR 55.13, supervising a student or trainee at the controls. Additionally, the facility deviated from Technical Specification 6.1.3.1.a), which requires the presence of a licensed operator in the control room during operations.

"At no point was the health and safety of the public or MSTR in doubt. The operator remained physically capable of performing licensed duties during the non-compliant periods and successfully underwent medical evaluation on April 10, 2026.

"This report is being made under the provisions of MSTR Technical Specification 6.7.2, requiring a report by telephone to the NRC Headquarters Operations Center no later than the following working day. Under the provisions of MSTR Technical Specification 6.7.2, a written follow-up report will be submitted to the Commission within 14 days.

"This event will be entered into the facility Corrective Action Program as CAP-2026-003, and the facility project manager will be notified."