Event Notification Report for September 23, 2026

EN Revision Imported Date: 9/23/2026

EN Revision Text: AGREEMENT STATE REPORT - LOST IODINE SEED

The following information was received from the New York State Department of Health, Bureau of Environmental Radiation Protection (the Department) via email:

"On January 29, 2026, the Department was notified of a missing iodine-125 localization seed (48 microcuries) at a medical facility located in New York State.

"The I-125 localization seed was removed from storage for implantation into a patient on October 30, 2025. During the quarterly inventory performed on December 30, 2025, the licensee discovered that the I-125 localization seed was not in the storage facility. Surveys of use areas were performed but the seed was not recovered. The facility believes that the seed (which was pre-loaded into a needle) was discarded in the sharps container and was still within the lead shielding."

NY Event Report ID: NY-26-02
NY Incident Number: 1553

* * * UPDATE ON SEPTEMBER 22, 2026, AT 1102 EDT FROM NATHANIEL KISHBAUGH TO ERNEST WEST * * *

"[The] lost source was a BEST Medical Model 2300 I-125 radioactive localization seed. Activity on date of removal from storage (October 30, 2025) was 97 microcuries and was 48.3 microcuries on the date it was declared as lost (December 30, 2025). Licensee confirms that probable disposition was in the sharps container and estimates the unintended dose to a member of the public from exposure to this source to be less than 1 mrem. Activity indicates that the I-125 seed is approximately 2.1 microcuries as of [September 22, 2026].

"As of [September 22, 2026], the localization seed is missing. Following the discovery of this missing source, the licensee attempted on several occasions to locate the seed, had interviewed staff, and presented this case to a standing working group consisting of medical health physics staff, radiology management, and the primary breast imaging specialist for each site for awareness and collaboration. As a preventative measure, the licensee committed to having two individuals concurrently update and account for I-125 seeds as a checks and balance to reduce the chance of inadvertent disposal, misplacement, etc. in the future.

"These corrective actions and preventative measures have been accepted by New York State Department of Health (NYSDOH). Subsequently, this event under Incident Number 1553 has been closed. The licensee has been reminded of requirements to notify NYSDOH of any emergent information on this source in accordance with New York State requirements equivalent to 10 CFR 20.2201(d). Should new and relevant information arise following the closure of this event, the incident may be reopened, and an additional update will be provided to NMED as soon as possible."

Notified NMSS Events Notification (email), ILTAB (email), and CNSC (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 - MEDICAL EVENT

The following is a summary of information provided by the Washington State Department of Health via email:

An investigational therapeutic dose of Pb-212 was delivered to the licensee with an activity of approximately 7 mCi, at a concentration of approximately 1 mCi/mL. The vial was to be used to administer a prescribed dosage of 6 mCi after decay.

Due to the pharmaceutical's limited expiration window, the licensee did not wait for decay to the prescribed dose and removed approximately 1mCi using a syringe. Using a pump assisted gravity method, the infusion began per protocol. The procedure was halted shortly after it began due to significant leakage from the vial. It was determined that approximately 1.5 mCi had been administered successfully. The leakage was contained in the vial shield and protective gauze, and surveys of personnel and surrounding areas confirmed there was no additional contamination.

The patient and referring physician were notified and a detailed report will follow within 15 days.

Washington incident number: WA 26-011

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 - LOST MOISTURE DENSITY GAUGES

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

"The Agency received notification of two Troxler moisture density gauges lost in transport through [a common carrier]. The two missing gauges are a model 3440P (S/N 75617) last scanned September 4, 2026, and picked up in Ft. Worth, TX, and a model 4640 (S/N 79810), last scanned August 29, 2026, in Hutchins, TX. The model 3440P has an 8 mCi Cs-137 and a 40 mCi Am-241/Be source. The model 4640 has an 8 mCi Cs-137 source. Both gauges were shipped out of the Fort Worth area through [a common carrier] with the 3440P going from Fort Worth to Amarillo, Texas, back to the customer after servicing. The 4640 was going from Fort Worth to Baton Rouge, LA, for service. The licensee is still in contact with [the common carrier who is] actively searching for the missing gauges.

"Additional information will be made available according to SA300 reporting requirements as it becomes available."

Texas Incident Number: 10328
NMED number: TX260039

* * * UPDATE ON 09/19/2026 AT 0001 EDT FROM CARLEY CARDWELL TO ROBERT THOMPSON * * *

The following information was provided by the Agency via email:

"The licensee has received confirmation from [the common carrier] that the Troxler model 3440P gauge was located in Lubbock, TX, and is enroute to the customer. The licensee is still actively looking for the second gauge, the model 4640, that was enroute to Baton Rouge, LA.

Notified NMSS Events Notification (email), NSIR DSO ILTAB (email), CNSNS (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

POTENTIAL LOST OR STOLEN SOURCE

The following information was provided by the US Army via phone:

On September 16, 2026, the licensee's radiation safety officer (RSO) discovered a closed eBay listing in Hartselle, Alabama with an M67 mortar sight unit, and M58 and M59 aiming post lights. The listing closed on July 10, 2026. It is unknown if the items contain the tritium sources at this time, but the data plates were not visible in the listing photos. The M67 unit originally contained a 5.8 Ci tritium source, and the M58 and M59 lights originally contained either 5 or 9 Ci tritium sources. The origin of this material is unknown at this time, but was previously owned by either the US Army or US Marine Corps. The RSO plans on reporting this to his chain of command and to the Army legal department to investigate the providence of the items and if they were legally obtained and sources removed prior to selling on eBay.


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