Event Notification Report for March 24, 2026

AGREEMENT STATE REPORT - OVEREXPOSURE

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

"On 03/02/2026, a report was sent to the Department regarding an occupational overexposure. The report indicates that an individual received 5.151 rem total effective dose equivalent for the year 2025. This exceeds occupational dose limits specified in 10 CFR 20.1201(a)(1)(i) and must be reported per 10 CFR 20.2203(a)(2)(i) within 30 days after learning of the occurrence. The licensee became aware of the overexposure during review of dosimetry records on 02/19/2026 and submitted their report to the Department within 30 days, as required.

"The licensee is a mobile imaging service provider based in a non-Agreement State [South Dakota] and the individual exceeding the occupational dose for the year 2025 was a traveling nuclear medicine technologist (NMT). The exposure is believed to have occurred due to work procedures and air travel. The individual had taken 42 one-way work flights in 2025 and indicated that he had left the badge in carry-on luggage an unspecified number of times. The individual was informed that they should not be putting their badge through the Transportation Security Administration (TSA) scanner. The report also details that the individual was found to be using poor dose handling techniques during positron emission tomography (PET) scans which led to higher-than-expected doses. The individual was informed that they should review their work procedures for possible reduction of exposure and to apply the rules of time, distance, and shielding to keep exposures as low as reasonably achievable (ALARA). These communications were made by the radiation safety officer (RSO) to the individual in ALARA 1 notifications and other meetings throughout 2025.

"In December of 2025, it was discovered that the individual had lost their December badge and could not recall the date. The licensee provided the individual with a spare badge and using a calculation of an average of the previous 3 months, assigned 775 mrem to their body badge.

"The corrective actions for this incident included retraining the individual, resending radiation safety policies and procedures to the individual, and a personalized ALARA improvement plan which was implemented to correct behaviors, work practices, and planning deficiencies to reduce the employee's radiation exposure. The individual's dosimetry records will also promptly be reviewed and any quarterly dose exceeding 1250 mrem will result in stopping all work in radiation areas for a period to reduce employee exposures below the required limits.

"This incident is being tracked under Incident No. 1556. The corrective actions have been deemed acceptable to the Department and this incident has been closed."

NY Event Report ID: NY-26-03
NY Incident Number: 1556

AGREEMENT STATE REPORT - LOST I-125 SEED

The following information was received from the Massachusetts Radiation Control Program (the Agency) via email:

"On March 11, 2026, one radioactive iodine-125 sealed source (seed) was removed from a patient receiving a radioactive seed localization procedure. The licensee expected to remove two iodine-125 seeds, which were placed in the patient on March 10, 2026, but only located one of the seeds. The activity of the missing seed is 0.167 mCi. The missing seed manufacturer is IsoAid, LLC. The model number of the seed is IAI-125A.

"The missing seed was not located after extensive surveys of the patient, patient's car and home, staff, and all areas where the seed may have been misplaced. The seed has not been located at this time.

"The reporting requirement is within 30 days and is 105 Code of Massachusetts Regulations (CMR) 120.281(A)(2), missing licensed radioactive materials in aggregate quantity equal to or greater than 10 times quantity specified in 105 CMR 120.297, Appendix C.

"The Agency considers this event to be open."

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 information was provided by the Illinois Emergency Management Agency (the Agency) via phone and email:

"The Agency was contacted by a consultant for Methodist Medical Center of Illinois to report that a patient, treated with Y-90 Theraspheres to the right hepatic lobe last month, was scheduled for a Y-90 Theraspheres treatment to the left hepatic lobe on Friday, March 13, 2026. Angiographic images taken just prior to the Y-90 administration confirmed the proper placement of the microcatheter tip to the 2 left hepatic arterial branches; however, after the treatment, single photon emission computed tomography (SPECT)/computed tomography (CT) imaging only showed activity in the right hepatic lobe.

"The authorized user (AU) reported that the catheter tip must have prolapsed into the adjacent right hepatic artery during administration, causing the activity to go to the right hepatic lobe again. No untoward effects are expected to the patient since the dose was distributed within the right hepatic lobe in a similar distribution pattern (into the hepatic metastases) at the previous post treatment scan with the exposure predominantly at the site of the disease. The AU performing the treatment wants the patient to get a Cu-64 dotatate scan in 4 weeks to evaluate whether there has been a favorable response achieved in the right lobe from the Y-90 and then schedule the patient for a Y-90 treatment to the left hepatic lobe. At this time, the licensee has confirmed that the patient was notified but is still gathering information regarding notification of the referring physician.

"This matter is reportable under 32 Illinois Administrative Code 335.1080(a)(1)(C) no later than the next calendar day after discovery of the medical event. Reporting requirements were not met by the licensee and will be addressed through forthcoming inspection correspondence.

"A reactive inspection will be conducted next week to interview staff, review documents and images, and gather information as to root cause and proposed corrective actions."

Illinois Item Number: IL260008

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 is a summary of information provided by the Radiation Health Branch (RHB) of the Kentucky Department for Public Health and Safety via email:

RHB reported that the licensee had an incorrect tagging agent for some Cardiolite [Tc-99m] doses and several patients were affected. Patients were injected, but the isotope didn't go where intended for imaging. The patients were re-dosed with the properly tagged isotope.

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 I-125 SEED

The following information was received from the Virginia Radioactive Materials Program (VRMP) via email:

"On February 17, 2026, the licensee discovered and reported a lost I-125 [radioactive seed localization (RSL)] seed with an activity of 0.1186 mCi that was placed in a patient on February 16, 2026. Two seeds were implanted on February 16, 2026, and only one seed was found in surgery on February 17, 2026. A thorough search, including an extensive survey, was performed by the licensee, but the seed was not located.

"The seed meets the reporting requirement of 30 days from discovery.

"The licensee provided a report that included an acceptable root cause analysis and corrective action plan on February 26, 2026. The licensee determined the cause to be an inadequate procedure for implant/removal of RSL seeds and will revise their implant/removal procedure to better locate and account for all seeds placed."

Virginia event report number: VA260002

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 - DAMAGED TROXLER GAUGE

The following information was provided by the Utah Department of Environmental Quality, Division of Waste Management and Radiation Control (the Division) via email:

"During a routine inspection on March 17, 2026, the inspectors identified an incident that occurred on approximately June 20, 2025, that was not reported to the Division. The licensee performed work at a temporary jobsite using a Troxler moisture density gauge (model: 3440P, serial number: 89320, isotope: Am-241:Be/40 mCi, Cs-137/9 mCi). The gauge operator was loading the bed of his truck and left the gauge sitting on the ground and a recreational vehicle (four-wheeler) ran over the gauge. The sources were in a safe, shielded position and were not exposed at the time the gauge was run over. Although the damage to the gauge was minor, the gauge exposure handle was bent which prevented the licensee from exposing the source rod. The licensee plans to send the gauge to the manufacturer for repair or disposal.

"Additional information will be provided in the NMED submittal."

Utah event report ID number: UT 260004