Event Notification Report for July 22, 2026

EN Revision Imported Date: 7/22/2026

EN Revision Text: AGREEMENT STATE REPORT - OCCUPATIONAL DOSE EXCEEDANCE (EXTREMITY)

The following is a summary of information received from the New York State Department of Health Bureau of Environmental Radiation Protection (NYSDOH) via phone and email:

NYSDOH was notified on January 22, 2025, that an interventional radiologist had exceeded the occupational dose for extremities (50 rem in a calendar year) for 2024. The radiologist routinely performs yttrium-90 microspheres and x-ray fluoroscopic procedures, and it is unclear what the primary cause is of this overexposure. The left-ring badge dosimeter for this authorized user indicated doses of 92.395 Rem for year 2024. This investigation will include the procedure(s) that have been performed to outline potential causes for these elevated extremity doses.

The licensed medical facility's radiation safety officer immediately provided a written notification to the affected authorized user and is performing a root cause analysis to further identify primary and contributing causes of this overexposure. NYSDOH is closely monitoring this event and has assigned NYSDOH incident No. 1513. More information will be provided to NMED once available.

NY event number: NY-25-01

* * * UPDATE ON 07/21/2026 AT 1455 EDT FROM NATHANIEL A. KISHBAUGH TO SEBASTIEN BRUNEAU * * *

The following update was provided by the NYSDOH via email:

"Upon further review of the Landauer report for this left-ridge badge, it was determined that 78.9 rem was reported for the wear period of October 2024, constituting 85.4 percent of the user's left-ring extremity dose for the calendar year.

"An investigation and root cause analysis were performed by the licensee. This investigation consisted of interviews with the authorized user, review of case logs and imaging, and dose reconstruction. The extremity ring badge underwent additional investigation by Landauer specialists, which confirmed the absence of any anomalies identified for the dosimeter and the reliability of the original dosimetry reports.

"The licensee concludes that the exceedance of the annual limit is the sum of several factors, including the authorized user's left hand located within the primary beam of fluoroscopic procedures in two of the thirty cases performed during the month of October. Dose reconstruction was performed by a licensed medical physicist, which determined a likely dose of approximately 2.3 rem from these two fluoroscopic procedures to the left hand. Yttrium-90 microsphere procedures at this facility are physically attended by radiation Safety staff. Staff did not note or recall any improper preparation, administration, or handling of microspheres, and further surveys and record/case reviews confirmed that all procedures were satisfactorily completed within the required administration range. Furthermore, no contamination was noted from these procedures. The authorized user did note that their left-ring badge had fallen off within the fluoroscopy suite and remained within the fluoroscopy suite during other procedures before being found and returned to the dosimeter storage area. The licensee suspects that the lost ring-badge within the fluoroscopy suite may constitute the majority of the 78.9 rem reported for October 2024. However, such conclusion cannot be confidently confirmed given information available at the time of investigation.

"The licensee has implemented several changes to prevent recurrence: The physician/authorized user was retrained and counseled on proper personnel monitoring wear and maintenance. Radiation safety will review physician's fluoroscopy cases monthly for one year to report to the radiation safety committee. Radiation safety will personally exchange dosimeters monthly for one year to ensure accurate, timely reporting.

"Following this event, no additional issues have been reported to the Department for this physician/authorized user or other individuals who have been issued personnel dosimetry.

"Subsequently, NYSDOH Incident No. 1513 has been closed."

Notified R1DO (Dentel), and NMSS Events Notifications (email).

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was provided by the Ohio Bureau of Radiation Protection via email:

"On July 13, 2026, the licensee's radiation safety officer notified the Ohio Department of Health (ODH) of a possible medical event involving a Y-90 TheraSphere microsphere administration. A patient was to receive a prescribed dose of 200 gray (Gy) to the target liver-segment. After administration, calculations of residual activity in the delivery system determined that the patient only received 154.8 Gy, a 23 percent difference less than the prescribed dose. The licensee does not believe the patient reached stasis and does not recall any issues during the delivery of the Y-90 microspheres. The patient was not harmed. The licensee will provide a report to ODH within 15 days of notification."

Ohio Event number: OH260003

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 TROXLER GAUGE

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

"On July 13, 2026, Interra, Inc. the licensee, reported that a nuclear density gauge stopped working at a job site the previous day. The licensee was contacted by the Agency on July 14, 2026, for additional information. At that time, the licensee reported that a Troxler 3440 gauge (CS-137 10 mCi, Am-241 40 mCi, serial number: 31625) had been run over by a roller on July 12, 2026, damaging the gauge handle. The licensee reported that the source rod was not extended when the incident occurred. Information obtained indicated that emergency procedures were followed. The designated alternate radiation safety officer responded to the scene with a radiation survey instrument. Surveys were conducted and results indicated no leakage and proper shielding of sources. The transport case was reported as undamaged, and the gauge was able to be placed in its shielded transport container. A second survey was conducted on the morning of July 13, 2026, and the bent source handle was secured to the gauge housing with duct tape. Once secured, the gauge was transported to Troxler in Downers Grove, Illinois for a leak test, full evaluation, and repair.

"A reactive inspection is scheduled to occur on July 15, 2026.

"This event will be updated as additional information is obtained."

Illinois Item Number: IL260021

AGREEMENT STATE REPORT - STUCK SHUTTER

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

"On July 15, 2026, the Agency received a notification from the licensee regarding a stuck source shutter on a density gauge. The gauge, a Vega SHF2 Model, contains a 200 millicurie cesium-137 sealed source. The licensee reported that the gauge was found with the source shutter stuck in the open position by technicians conducting routine shutdown operations at the facility on July 14, 2026. Open is the normal operating position. The licensee stated that no worker or members of the public received an unintended radiation dose as a result of this event. The licensee has also arranged the contractor to repair the gauge on July 17, 2026.

"Additional information will be made available in accordance with SA 300 reporting requirements."

Texas Incident Number: 10308
Texas NMED Number: TX260024

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was provided by the Kentucky Department for Public Health and Safety, Radiation Health Branch (KY RHB) via email:

"KY RHB was notified on 7/15/2026, by email and phone conversation with the radiation safety officer (RSO) of Baptist Health Louisville, KY that a patient was administered the wrong radiopharmaceutical on 7/14/2026. A cardiac study patient was prescribed 30 mCi Tc-99m Tetrofosmin (Myoview) but received a dose of 5 mCi Tc-99m Mebrofenin (Choletec). A hepatic dose had been left in the dose calibrator, and the technologist selected that dose instead of the intended cardiac dose. After injection, the technologist noticed the intended dose sitting behind the dose calibrator workbench and immediately contacted the RSO. Dose calculations were compiled by a physics consultant and submitted to the RSO, and no apparent effects to the patient were determined. Additional dose calculations will be provided.

"The cause was determined to be human error. Corrective actions included work-process clarifications and retraining.

"Immediate notifications were made to the authorized user, the patient's ordering physician, and the patient."

KY Event Number: KY 26-0013

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 07/16/2026 AT 1420 EDT FROM ANGELA WILBERS TO CHRISTOPHER PRESCOTT * * *

The following information was provided by the Kentucky Department for Public Health and Safety, Radiation Health Branch (KY RHB) via email:

"Supplemental information indicates the event does not reach reportable criteria."

Dose comparison provided by KY RHB.

Notified R1DO (Carfang), NMSS Event Notifications (email), and acting NMSS Events Coordinator (DiMarco)