Event Notification Report for June 16, 2026

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was provided by the Louisiana Department of Environmental Quality (LDEQ) via email:

"On June 6, 2026, LDEQ was notified of a medical event involving a Gamma Knife facility at the Thomas J. Moran Imaging Center in Baton Rouge, Louisiana. The patient was being treated for trigeminal neuralgia (facial nerve pain on the left side), not cancer. Gamma Knife was selected as the treatment, to deliver a high dose to a small target volume (80 gray).

"The oncologist and neurosurgeon contours down to the small size of the nerve for treatment. For this incident, the physician prescribed, planned, consented, and contoured to a nerve on the patient's right side.

"Treatment began as prescribed. Approximately one-third of the way through, after delivery of 23.8 gray, staff noticed a discrepancy and stopped the procedure. It was then discovered that the treatment had been directed to the wrong side of the patient's face.

"The prescription and plan were corrected, and the patient subsequently received the intended 80 gray dose to the correct nerve on the left side."

LA Event Report ID: LA 20260009

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 PACKAGE

The following is a summary of information provided by the Illinois Emergency Management Agency (the Agency) via phone and email:

The Agency was contacted by Bard Brachytherapy to report that they had received a TechneLite Tc-99m generator via common carrier. This material was intended for a recycling facility in New York. The involved parties are attempting to contact the New York recycling facility. The package contents have decayed to background and there are no contamination or exposure concerns, and licensee has secured the materials. This incident is being reported as a lost package. The cause appears to be a dangerous goods label from another package, being placed on this package during transit.

* * * UPDATE ON 06/10/2026 AT 0938 EDT FROM KIMBERLY STICE TO JOSUE RAMIREZ * * *

The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:

"The intended recipient (New York based MediRay) was contacted, as well as the original shipper (Jubilant Radiopharmacy). Jubilant Radiopharmacy has arranged to pick up the package, place it back in commerce, and ship to its intended destination. The party in possession of this package (Bard) is appropriately authorized and well suited for storage of the materials while awaiting pickup. Corrective action is not possible as the common carrier is exempt from licensure. From all data available, it appears appropriate procedures were followed by all licensees involved. This matter is considered closed."

Notified R3DO (Gilliam), NMSS Events Notifications (Email), and ILTAB (Email).

Illinois Item Number: IL260014

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 New Mexico Environment Department via phone and email:

During an intravenous administration of 130 microcuries of Xofigo (Ra-223 dichloride) via the left hand, the patient experienced a burning sensation. The nuclear medicine technologist stopped the administration. The authorized user (AU) determined that an infiltration of Xofigo had occurred in the left hand of the patient and began intervention techniques (i.e., warm compress, massage, arm elevation, etc.). Shortly after the infiltration, the nuclear medicine technologist administered the remaining Xofigo dosage through the patient's right hand per the instructions of the AU. Count rate measurements and imaging was performed on the infiltrated site (patient's left hand) on June 3, 2026, and June 4, 2026. Activity and dosimetry calculations were performed, and results were confirmed on June 8, 2026. It was determined that 14 microcuries of Ra-223 infiltrated in the patient's left hand, which resulted in a dose of 3.2 Sv to the skin of the left hand. The licensee has performed a couple of follow-up visits with the patient to monitor symptoms and will continue observation over the next several weeks for any deterministic effects.


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 - DAMAGED SOURCE

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

"On June 9, 2026, the Department was notified by the licensee that a Troxler model 4640-B was run over at a job site, the plastic case was damaged, and the source rod appeared to be bent. Because the source rod appeared to be bent, they did not attempt to operate it. The gauge contained an 8 millicurie cesium-137 source. The radiation safety officer (RSO) stated the gauge would be returned to the normal storage area and on June 10, 2026, taken to the manufacturer for inspection. The RSO stated they were traveling to meet the technicians who were using the gauge and would perform radiation surveys of the gauge once they had possession of it. The RSO stated, based on the pictures, it did not appear that there was a risk of additional exposures. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident #: 10301
Texas NMED #: TX260020