Event Notification Report for January 24, 2025

AGREEMENT STATE REPORT - STUCK OPEN SHUTTER

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

"On January 24, 2025, the Department was notified by the licensee that on January 24, 2025, the shutter on a Vega model SH-F2 gauge failed in the open position during routine testing. The gauge contains a 500 millicurie (original activity) cesium-137 source. The licensee reported there is no risk of additional radiation exposure to members of the general public or radiation workers due to this mechanism failure. The licensee is in the process of scheduling a source holder service contractor to evaluate and attempt repairs to the source holders. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: I-10159
Texas NMED Number: TX250006

MEDICAL EVENT

The following is a summary of the information provided by the licensee via phone:

On January 24, 2025, at approximately 1000 MST, a 33.9 mCi Tc-99 cardiac stress test was administered to the wrong individual. The radiation safety officer reported that the effective dose equivalent and risk of functional damage to the patient were still being determined.

The patient has been notified. This incident is under investigation.

* * * RETRACTION ON 01/24/25 AT 2004 EST FROM MICHAEL HART TO JOSUE RAMIREZ * * *

After further investigation, the radiation safety officer determined that this incident did not meet reportability criteria.

Notified R4DO (Deese), NMSS (Allen), and NMSS Events Notification (email).

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.

MEDICAL EVENT

The following information was provided by the licensee's radiation safety officer (RSO) via phone:

During an audit performed on 04/16/2025, it was discovered, that on 01/24/2025, a patient had received a dose to the liver that was greater than 20 percent of the prescribed dose. The prescribed activity was 24.3 mCi of Y-90 microsphere, an equivalent dose of 21.95 grays to the liver. The spreadsheet containing the activity verification incorrectly listed the activity as 26.9 mCi. The actual activity administered to the patient was 29.8 mCi, an equivalent dose of 26.9 grays, which is 22.6 percent (4.95 grays) greater than the prescribed dose to the liver. The RSO intends to contact the patient and doctor.

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.