ENS 56969

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v t e ENS Event
14:00 Feb 5, 2024
Title	Lost Source
Event Description	The following information was provided by the New York State Department of Health (the Department) via fax: The radiation safety officer for Cardinal Health (New York State (NYS) Radioactive Materials License (RAML) C3046) noted a missing vial of ln-111 oxyquinoline (oxine) on the morning of 02/05/24. The Administrative Director phoned NYS Department of Health (DOH) on 02/06/24 at 1500 EST, to report the missing vial. The vial contained approximately 1 millicurie of ln-111 at the time of transfer. The sealed vial was shipped from the Cardinal Health facility, RAML C2593, in Bronx, NY, by company courier, received at [the Plainview facility], RAML C3046, and subsequently lost. This shipment was a transfer between Cardinal Health facilities and not to the end user for clinical administration. To date, Cardinal Health has not located the vial, but is actively attempting to locate its whereabouts and investigate the root cause. Based on information at this time, external radiation levels outside of the shipping container would not likely pose any concern or adverse health risks to members of the public, including couriers. As of the date and time of this notification, the expected activity of the vial is estimated to be 0.56 millicuries and will rapidly decay to background levels provided the short half-life of ln-111 (2.8 days). In accordance with 10 CFR 20.2201(a)(ii), the activity of ln-111 was approximately 10 times the quantity specified in Appendix C to 10 CFR 20, which prompts a 30-day telephone report and subsequent written report within 30 days of the initial notification to the Department. It is possible that due to the short half-life, this vial may in actuality contain less than the reportable quantity prescribed by 10 CFR 20.2201(a), however, this event is being reported out of an abundance of caution as the circumstances around this lost vial are not immediately available. NYSDOH is actively monitoring this incident and has assigned incident number 1474 to track this event. Cardinal Health is currently working through the initial investigation of this event, and anticipates submitting a thorough outline of their investigation, primary and contributing causes, and steps to prevent recurrence as prescribed in addition to all items prescribed by 10 CFR 20.2201(b), under NYS (10 NYCRR 16.15) requirements. New York State Event Report Number: NY-24-01 * * UPDATE ON 9/17/2024 AT 1517 EDT FROM NATE KISHBAUGH TO ROBERT THOMPSON * * * The following information was provided by the New York State Department of Health (NYSDOH) via email: Cardinal Health (the licensee) provided a description of the event, actions taken to attempt to recover the vial, and preventative measures to prevent recurrence. The licensee interviewed staff, performed recovery surveys, and provided an investigation to attempt to locate this source. It is believed that this In-111 vial was placed on a cart with return waste in a similar delivery case, and it was inadvertently mistaken as returned customer waste. The vial was likely placed into decay-in-storage. To date, the vial in question has not been recovered and has decayed to background levels. To prevent recurrence, delivery personnel are required to immediately sign all acknowledgements of receipt prior to transferring the package and leaving the facility. NYSDOH has accepted these corrective actions and will evaluate them on the next inspection. This event was closed by NYSDOH. Notified R1DO (Werkheiser), NMSS Events Notification (email), ILTAB (email), Canadian Nuclear Safety Commission (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

ENS 56969 +/-
Where
Cardinal Health Plainview, New York (NRC Region 1)
License number:	C3046
Organization:	New York State Dept. Of Health
Reporting

Agreement State
Time - Person (Reporting Time:+235.82 h9.826 days <br />1.404 weeks <br />0.323 months <br />)
Opened:	Daniel Samson 09:49 Feb 15, 2024
NRC Officer:	Bill Gott
Last Updated:	Sep 17, 2024
56969 - NRC Website
v • d • e

v t e Emergency Notification System
Cardinal Health with Agreement State
WEEKMONTHYEAR2024-09-27T09:00:00 [Table view]
[ENS list for Cardinal Health]

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ENS Notification