Event Notification Report for April 10, 2026

EN Revision Imported Date: 4/10/2026

EN Revision Text: AGREEMENT STATE REPORT - LOST MEDICAL SOURCE

The following information was provided by the Florida Bureau of Radiation Control via email:

"On April 1, 2026, at approximately 1315 EDT, a radioactive medical source was identified as missing from Moffitt Cancer Center in Tampa, Florida. It was discovered that the drug Lutathera, which is a lutetium-177 (Lu-177) medical unsealed source used for intravenous therapy, had been accidentally discarded on March 31, 2026, at approximately 1600 EDT by a nuclear medicine technician. At the time of disposal, the activity was approximately 221 millicuries (mCi), and it was scheduled for patient administration on April 1, 2026, at an activity of approximately 202 mCi. The source has a half-life of 6.65 days. The source was fully sealed in its original packaging in a lead pig. Trash collection had already taken place before the source had been reported missing. The source is believed to have been transported to a landfill. Due to the sealed packaging and shielding, the risk of environmental contamination or public exposure is considered low. The source is expected to decay in the landfill because of its short physical half-life."

Florida incident number: FL26-029

* * * UPDATE ON 04/09/2026 AT 1238 EDT FROM KENDRA COOPER TO TENISHA MEADOWS * * *

The following information was provided by the Florida Bureau of Radiation Control via email:

"Material was identified in a Reworld Hillsborough post burn pile. Reworld has been advised on disposal."

Notified R1DO (Dentel), NMSS Events Notification (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

POTENTIAL MEDICAL EVENT

The following information was provided by the licensee via phone:

On April 1, 2026, the radiation safety officer (RSO) at BAMF Health Clinic received notification from their clinical trial sponsor, Heart Bio, that they identified unexpected trace amounts of thorium-228 in their ARTISAN AB001-101 trial medication that is currently being tested and administered via intravenous injection. The sponsor's preliminary dose analysis estimated that four different organs and tissues will receive over 50 rem to each organ from the thorium contaminate. The RSO is assisting Heart Bio in their investigation to identify the full scope of patients affected by the medication. The treating physician and the Food and Drug Administration (FDA) has been notified. The sponsor and an independent institutional review board are working with the RSO to notify the research patients.

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