Event Notification Report for July 08, 2025

MEDICAL EVENT

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

A planned treatment administering three Y-90 microsphere doses resulted in underdoses of greater than 20 percent for all three doses. The start of the treatment was delayed as the treatment room was not available at the scheduled time. Doses were dispensed assuming a treatment time of 0930 CDT, but actual treatments were delayed until 1118, 1156, and 1244 CDT, respectively. The licensee is also investigating a potential complication in establishing intravenous access to the treatment site (liver).

Actual doses planned and administered were as follows:

First treatment at 1118 CDT: planned 18.9 mCi, actual 14.1 mCi
Second treatment at 1156 CDT: planned 13.8 mCi, actual 10.1 mCi
Third treatment at 1244 CDT: planned 17.2 mCi, actual 12.0 mCi

Initial review by the authorized user has concluded the treatments administered were adequate and no further treatment is planned.

The attending physician and patient are being notified.

An NRC Region III inspector was on-site and has been notified.

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 SOURCE

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

"Adventist Health Systems radiation safety officer (RSO) called today at 1603 EDT to report a lost source while in transit with [common carrier]. The source was a rod source of Gd-153 being shipped in a lead sleeve. The activity of the Gd-153 source at the beginning of July 2025 was 0.04 mCi. The RSO was first notified on July 8, 2025, of the source not arriving at the destination of Eckert and Zeigler in Burbank, California. An employee with Eckert and Zeigler confirmed the box was empty when received on July 7, 2025. There was no source or lead sleeve in the box. They took one picture of the box, then disposed of the box. The RSO has been investigating this incident since July 8. He said the [common carrier] told him that the box was weighed at the midpoint of the shipment in Memphis and the box weight was unchanged from when it left Orlando. He also said anti-tamper tape was placed on the box, but it was unknown if the tape was intact upon arrival at Eckert and Zeigler. There is an ongoing investigation between Adventist Health and the [common carrier]."

Florida Incident Number: FL25-074


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 - LOST TREATMENT VIAL

The following information was provided by the Nevada Division of Public and Behavioral Health via phone and email:

"On July 8th, a Xofigo package [containing liquid Ra-223 dichloride solution of an unknown total activity] was checked in, and subsequent procedures were carried out for dose verification and disposal. However, the dose was later found to be missing, prompting an investigation.

"Upon receipt, the surface radiation level of the package was measured at 1.8 mR/hr. Wipe tests performed on both the inside and outside of the package registered 122 dpm. [There is no contamination concern at this time.]

"The dose was then checked into inventory as per protocol. The radioactive warning symbols on the package were defaced and physically removed. The package box was placed around the corner for the cleaning staff to dispose of.

"The following day, when attempting to retrieve the dose from the storage cabinet, it was discovered that the dose was missing. It was realized that during the initial wipe test, the dose had not been removed from the box before disposal. Efforts to locate the missing dose included checking outside trash bins, but these had already been emptied that morning. [The licensee] contacted maintenance personnel who liaised with the cleaning company and waste management services. Waste management confirmed that there is no method available to locate the missing dose and that it is likely disposed of in the main trash area.

"The Xofigo packaging weighs nearly the same whether it contains the dose or not, due to the plastic pig inside. To prevent recurrence, a new process has been implemented: the Styrofoam lid will be removed and discarded immediately after wiping to confirm the box is empty. Additionally, the entire box will now be discarded only after the dose has been administered to the patient."

[The typical full manufactured container amount is 6.6 MBq/vial]

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