Event Notification Report for July 25, 2025
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/24/2025 - 07/25/2025
Agreement State
Event Number: 57830
Rep Org: Florida Bureau of Radiation Control
Licensee: ADVENTIST HEALTH SYSTEMS
Region: 1
City: Altamont Springs State: FL
County:
License #: 2897-1
Agreement: Y
Docket:
NRC Notified By: Monroe A. Cooper
HQ OPS Officer: Ernest West
Licensee: ADVENTIST HEALTH SYSTEMS
Region: 1
City: Altamont Springs State: FL
County:
License #: 2897-1
Agreement: Y
Docket:
NRC Notified By: Monroe A. Cooper
HQ OPS Officer: Ernest West
Notification Date: 07/28/2025
Notification Time: 17:23 [ET]
Event Date: 07/25/2025
Event Time: 00:00 [EDT]
Last Update Date: 07/28/2025
Notification Time: 17:23 [ET]
Event Date: 07/25/2025
Event Time: 00:00 [EDT]
Last Update Date: 07/28/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Bickett, Carey (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Bickett, Carey (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was provided by the Florida Bureau of Radiation Control (BRC) via email:
"BRC was notified on 7/28/25 that on Friday, 7/25/25, a patient at Advent Health, Daytona was receiving Y-90 TheraSphere treatment for the liver. The patient received a dose which differed by more than 20 percent from the prescribed dose. Treatment was provided in 2 segments, denoted in 2 scripts. One segment received the full prescribed treatment, while the other segment received 51 percent of the intended treatment. Due to the treatment being provided as 2 scripts, treatment two differed by more than 20 percent.
"The [licensee's] radiation safety officer states that the dosimeter on the vial showed a dose of 0, but when all administration materials were removed, the residual within the equipment was much higher than expected. The primary care provider has been informed. It is unknown if the patient has been informed."
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.
The following information was provided by the Florida Bureau of Radiation Control (BRC) via email:
"BRC was notified on 7/28/25 that on Friday, 7/25/25, a patient at Advent Health, Daytona was receiving Y-90 TheraSphere treatment for the liver. The patient received a dose which differed by more than 20 percent from the prescribed dose. Treatment was provided in 2 segments, denoted in 2 scripts. One segment received the full prescribed treatment, while the other segment received 51 percent of the intended treatment. Due to the treatment being provided as 2 scripts, treatment two differed by more than 20 percent.
"The [licensee's] radiation safety officer states that the dosimeter on the vial showed a dose of 0, but when all administration materials were removed, the residual within the equipment was much higher than expected. The primary care provider has been informed. It is unknown if the patient has been informed."
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
Event Number: 57828
Rep Org: Maryland Dept of the Environment
Licensee: ECS Mid-Atlantic, LLC
Region: 1
City: Frederick State: MD
County:
License #: MD-21-037-01
Agreement: Y
Docket:
NRC Notified By: Krishnakumar Nangeelil
HQ OPS Officer: Ernest West
Licensee: ECS Mid-Atlantic, LLC
Region: 1
City: Frederick State: MD
County:
License #: MD-21-037-01
Agreement: Y
Docket:
NRC Notified By: Krishnakumar Nangeelil
HQ OPS Officer: Ernest West
Notification Date: 07/25/2025
Notification Time: 19:29 [ET]
Event Date: 07/25/2025
Event Time: 15:20 [EDT]
Last Update Date: 07/25/2025
Notification Time: 19:29 [ET]
Event Date: 07/25/2025
Event Time: 15:20 [EDT]
Last Update Date: 07/25/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Carfang, Erin (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Carfang, Erin (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - DAMAGED TROXLER GAUGE
The following information was provided by the Maryland Department of the Environment (MDE) via email:
"On July 25, 2025, at approximately 1520 EDT, the radiation safety officer (RSO) of Engineering Consulting Services Mid-Atlantic, LLC (ECS) reported an incident to MDE involving damage to a Troxler model 3440 portable nuclear gauge (serial number 30580). The incident occurred at a construction site located in Frederick, MD.
"According to the gauge technician, the roller operator initially passed the technician on the right side and then reversed the roller toward the testing site. Despite immediate attempts to alert the driver to stop, the roller continued reversing. Once the gauge operator realized the driver was not stopping, he quickly moved out of the roller's path. The gauge was subsequently struck by the roller.
"As reported by the RSO, while the gauge housing was damaged, there is no indication of a breach of the radioactive sources' integrity. The RSO conducted leak tests immediately after the incident and submitted the samples to North East Technical Services Inc. (NETS) for analysis. Results are currently pending. MDE has requested the licensee to transfer the damaged gauge to NETS as per the safety protocol and provide the leak test results, calibration records, and appropriate transfer and/or disposal documentation once the evaluation by NETS is complete. Decisions regarding repair or disposal of the gauge will be based on NETS' findings.
"Following removal of the gauge from the site, a radiation survey was conducted, and no elevated radiation levels above background were detected as per the RSO. MDE's radiological health program will continue to monitor and follow up on this reactive investigation until the device is either repaired or appropriately disposed of."
The following information was provided by the Maryland Department of the Environment (MDE) via email:
"On July 25, 2025, at approximately 1520 EDT, the radiation safety officer (RSO) of Engineering Consulting Services Mid-Atlantic, LLC (ECS) reported an incident to MDE involving damage to a Troxler model 3440 portable nuclear gauge (serial number 30580). The incident occurred at a construction site located in Frederick, MD.
"According to the gauge technician, the roller operator initially passed the technician on the right side and then reversed the roller toward the testing site. Despite immediate attempts to alert the driver to stop, the roller continued reversing. Once the gauge operator realized the driver was not stopping, he quickly moved out of the roller's path. The gauge was subsequently struck by the roller.
"As reported by the RSO, while the gauge housing was damaged, there is no indication of a breach of the radioactive sources' integrity. The RSO conducted leak tests immediately after the incident and submitted the samples to North East Technical Services Inc. (NETS) for analysis. Results are currently pending. MDE has requested the licensee to transfer the damaged gauge to NETS as per the safety protocol and provide the leak test results, calibration records, and appropriate transfer and/or disposal documentation once the evaluation by NETS is complete. Decisions regarding repair or disposal of the gauge will be based on NETS' findings.
"Following removal of the gauge from the site, a radiation survey was conducted, and no elevated radiation levels above background were detected as per the RSO. MDE's radiological health program will continue to monitor and follow up on this reactive investigation until the device is either repaired or appropriately disposed of."