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The following was received from the Illinois Emergency Management Agency (the Agency) via email: Representatives of Elmhurst Hospital (RML IL-01612-01) contacted the Agency at approximately 1230 CDT today, 6/29/22, to report a Y-90 Theraspheres administration that took place on 6/29/22 (approximately 1000 CDT) which resulted in 100 percent of the dose prescribed not being delivered. The pre and post surveys of the vial and delivery system were nearly identical, supporting the licensee's assertion that no microspheres were delivered. The patient was surveyed post-administration and was at background. While contamination was identified on the draping, it resulted from the disconnection of the delivery system when the administration was halted. No contamination was identified on the patient. Microspheres were observed clustered at the hub and none beyond. The licensee claims there were no kinks and the manufacturer's checklist was followed to include agitation/flushing. At this time, it is unclear if the patient and referring physician have been notified, but the licensee is aware of the requirement. The licensee is aware of the 15-day written report requirement. The AU ((Authorized User)) will be back in the office on Friday and understands the Agency will need additional information via a reactionary inspection. The Agency is scheduling a reactive inspection and this report will be updated as information becomes available. Illinois Item Number: IL220023

• * * UPDATE ON 9/01/2022 AT 1616 EDT FROM LLINOIS EMERGENCY MANAGEMENT AGENCY TO KAREN COTTON VIA E-MAIL* * *

The Agency conducted a reactive inspection on 7/1/22. At that time, no indications of root cause could be identified. The licensee's written report was received timely and presented no new information. The delivery kit was returned to the manufacturer for assessment when decayed. Subsequent information was submitted to the Agency for review. The licensee's written report was received timely. Documentation included Gamma camera images of the administration set up kit and catheter which appeared to show activity in the microcatheter. Based on images reviewed, the Agency cannot rule out that some activity may have been delivered to the patient. Due to the contamination, not all of the activity in the waste was able to be accounted for; however, the bulk of activity in the waste indicated that conservatively less than 8.9% of the dosage was delivered. Agency inspectors determined the potential root cause as clumping of microspheres between the D and E lines of the administration kit pending investigation/assessment of the administration kit by the manufacturer. The Agency will continue to monitor additional information provided by the licensee. This matter may be considered closed. Notified R3DO (Hills) and NMSS Event Notification via 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

The following was received from the New Jersey Department of Environmental Protection (NJDEP) via email: The NJDEP staff was notified of the loss of a 5 mCi syringe of Cu-64 from the Hackensack University Medical Center (NJ License no. 450695). The licensee contacted the NJDEP hotline at approximately 1933 EDT on 6/3/2022. The NJDEP staff was contacted at 1958 EDT. The NJDEP staff contacted the licensee RSO ((Radiation Safety Officer)) at 2002 EDT and asked for an update of the situation. The licensee RSO stated that the search for the syringe was continuing and that they contacted the isotope supplier to confirm its delivery. The supplier confirmed they had delivered the dose in the early morning of 6/3/2022. The NJDEP staff is monitoring the situation and more details will be provided as they become available.

• * * UPDATE ON 6/7/22 AT 0853 EDT FROM JACK TWAY TO KERBY SCALES * * *

The following update was received from the New Jersey Department of Environmental Protection (NJDEP) via email: A unit dose of Cu-64 calibrated for 4.4 mCi at 1500 EDT on 6/3/2022 (current activity estimated as 0.023 mCi) was discovered missing at Hackensack University Medical Center (NJ License no. 450695). The licensee reported the missing material to NJDEP who then reported the incident to NRC Operations Center. The NJ licensee followed up with their isotope suppliers to determine what might have happened to the dose. Video surveillance footage confirmed that the dose, in its Type A package was delivered by Nuclear Diagnostic Products to the Hackensack Nuclear Medicine PETCT Department at 0500 EDT on 6/3/2022. The driver was recorded on video leaving the Nuclear Medicine Department with a security guard and one black Type A package as expected. At 1020 EDT a driver from Medical Delivery Services, employed by Sofie Pharmaceuticals, was recorded delivering 1 Type A package and then leaving at 1022 EDT with 3 Type A packages, one of which bore the Yellow II label indicating it was not 'empty'. Sofie interviewed the driver who stated that he only picked up 2 packages, counter to what the video footage portrays. The driver has been suspended while Sofie continues to attempt to locate the package. Notified R1DO (Greives), NMSS Event Notifications and ILTAB via 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

The following was received from the Illinois Emergency Management Agency (the agency) via email: The Agency was contacted on 5/5/22, by GE Healthcare to advise that a radiopharmaceutical package was damaged in transit and reported as lost at the carrier's facility. GE Healthcare reports the 6 inch x 6 inch package (UN2915, Type A Package, Yellow II, TI 0.1) was shipped from Arlington Heights, IL to Richland, MS on 5/3/22. The package contained a lead shielded container with 1.956 mCi of In-111 (activity at the time of shipment on 5/3/22). The package reportedly arrived in one piece at the (common carrier's) Memphis hub on 5/3/22. On 5/5/22, the carrier advised the licensee that they had found the damaged package at their Memphis hub with its inner contents missing. Dangerous Goods is currently working with the shipper and conducting a search of the facility. The package now contains approximately 1.2 mCi (of In-111). There is no indication of intentional theft or diversion, and the contents would not be useful for illicit intent. This matter has a 30-day reporting requirement to the US NRC. Updates will be provided as they become available. Item Number: IL220015

• * * UPDATE ON 6/6/22 AT 1106 FROM GARY FORSEE TO KERBY SCALES * * *

The following was received from the Illinois Emergency Management Agency (the agency) via email: On 6/6/22, the licensee provided the required written report. The carrier has not provided any updates and the package is still lost. At this point, the radioactive material has decayed to less than 0.5 uCi. Pending no additional developments, this matter is considered closed. Notified R3DO (Szwarc) and R1DO (Grieves), and NMSS Event Notifications and ILTAB via 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

The following is a summary of information provided by the licensee via telephone: On 04/28/22, at 2355 EDT, with both Sequoyah Unit 1 and 2 in Mode-1, 100 percent, a Notice of Unusual Event was declared due to receiving two seismic alarms and security feeling ground movement. Additionally, security in a tower heard an explosion. Both units remain in Mode-1, 100 percent and they are investigating the validity of the seismic alarms before proceeding with the Abnormal Operating Procedure required shutdown. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The licensee will notify the NRC Resident Inspector. The state of Tennessee and the Tennessee Valley Authority were notified. Notified DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), DHS NRCC THD Desk(email), and DHS Nuclear SSA (email).

• * * UPDATE ON 04/29/2022 AT 0410 EDT FROM BRIAN KLEIN TO OSSY FONT * * *

The following is a summary of information provided by the licensee via telephone: On 4/29/22, at 0406 EDT, Sequoyah Unit 1 and Unit 2 terminated the Notice of Unusual Event. The Civil Engineers determined that the alarms were due to a failed seismic indicator channel. Through interviews, only one security officer felt ground movement for a couple of seconds and heard a faint rumbling sound. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The licensee will notify the NRC Resident Inspector. The state of Tennessee and the Tennessee Valley Authority were notified. Notified R2DO (Miller), NRR EO (Miller), and IR MOC (Gott) via email. Additionally, notified DHS SWO, FEMA Operations Center, CISA Central, FEMA NWC (email), DHS NRCC THD Desk(email), and DHS Nuclear SSA (email).

• * * RETRACTION ON 05/02/2022 AT 2118 EDT FROM SCOTT SEAL TO LLOYD DESOTELL * * *

The following information was provided by the licensee via email: SQN (Sequoyah Nuclear Plant) is retracting the previous NOUE (Notice of Unusual Event) declaration made on 4/28/22 at 2355 (EDT) based on Emergency Action Level HU2 for a seismic event greater than Operating Basis Earthquake levels. Following the declaration of the NOUE, the station reviewed all available indications and determined that a seismic event had not occurred. The instrumentation failure was documented under Event Notification #55867. Notified R2DO (Miller), and IR MOC (Gott), NRR EO (Miller) via email.

The following information was received from the Ohio Bureau of Radiation Protection via email: Report of a leaking General License Ni-63 source (Model: G2397A, S/N: U3951) on an Electron Capture Detector. The source was returned to the manufacturer. Leak test result: 20 microcuries (740 kBq) NMED Item Number: OH220004

• * * UPDATE ON 4/5/22 AT 1413 EDT FROM S. JAMES TO T. HERRITY * * *

UPDATES/CORRECTIONS ON LICENSEE NAME, ACTIVITY AND LEAK TEST RESULTS: Leak test was taken on Electron Capture Detector (ECD) in storage as part of 6-month cycle. ECD contained 15 mCi Ni-63 source. Results came back indicating leaking source at 2000 pCi. No contamination of the ECD was found. The ECD will be permanently taken out of service and returned to manufacturer. Licensee name updated to full name: Eurofins Environment Testing North Central, LLC Notified R3DO (McCraw) and NMSS Events via email.

The following was received from the Illinois Emergency Management Agency (IEMA) via email: The RSO ((Radiation Safety Officer)) for the licensee contacted IEMA to report that on March 2, 2022, a patient was administered a 100 mCi I-131 dose. A pregnancy test was performed in advance of the administration and indicated negative (not pregnant). On April 13, 2022, the RSO received a call notifying him the patient was determined to be 7 days pregnant when the administration occurred. The patient was informed and returned to the hospital to do a whole-body count as a means to estimate biological half-life. The licensee has calculated upwards of 20 microCi of I-131 was retained by week eleven of the pregnancy and 75 percent was taken up by the fetus. Dose prior to eleven weeks was reportedly estimated as that to the maternal uterus (ICRP 88 states this is accurate to 8 weeks). It is unclear if the calculation methodology used was consistent with RG 8.36 (NUREG/CR-5631) or ICRP 88 but will be reviewed when staff investigate. The licensee is estimating the dose to the fetus through 12 weeks of development as 266 mGy (26.6 rads). Illinois Item Number: IL220018

• * * UPDATE FROM GARY FORESEE TO BRIAN PARKS AT 1526 EDT ON 6/16/2022 * * *

The following was received from the Illinois Emergency Management Agency (IMEA) via email: A reactionary inspection was performed 6/2/22. The required 15-day report was received on 6/12/22 and put forward root cause and corrective action. The cause of the event was determined to be the ineffectiveness of the pregnancy testing policy to account for very early stage (i.e., first week of gestation) pregnancies that standard pregnancy tests cannot detect. The licensee revised its pregnancy testing policy to include patient instruction to abstain from intercourse for at least ten days prior to the administration of the dose. The licensee will be cited for failing to provide timely notification and corrective action to prevent a recurrence sought in the response. Pending no further developments and resolution of appropriate enforcement action, this matter is considered closed. Notified R3DO (Feliz-Adorno) and NMSS Events Notification E-mail Group.

The following was received via email from the Mississippi State Department of Health (the agency) via email: On 22 November 2021, the licensee notified the Agency by email regarding an incident that took place on 19 November 2021. The (Berthold Technologies) reciprocity crew, working under reciprocal recognition, was conducting turn around, replacing three gauge systems at the Licensee plant's Operating Processes. Two of the three sources retracted while one source was discovered to be stuck in the dip tube (Source Information: Co-60, 7.43 mCi, Manufacturer/Model: EG&G Berthold Model P-2608-100, Serial #: 1540-08-05, Device Information: Manufacturer EG&G Berthold, Device Model#: LB 7671, Serial Number: TBD). Reciprocity personnel attempted to dislodge the source to get it to retract but all attempts failed. The technician attached a blind plate (surveys below background) to prevent access and he documented surveys which the reciprocity personnel stated will be provided at a later time. According to the reciprocity licensee personnel, surveys were approximately 0.2 to 0.3 mR/hr at the detector side. Licensee personnel stated that the source is secured and remains shielded. Reciprocity licensee stated that they will continue to consider options to dislodge the source. The investigation into this event is ongoing and information will be provided as it is received in accordance with SA-300. Mississippi Item Number: MS-210003

• * * RETRACTION ON January 10, 2022 AT 1726 EST FROM ROBERT SIMS TO TOM KENDZIA * * *

The following information was received from the Mississippi State Department of Health (the agency) via e-mail: Investigation findings indicate this event is not reportable. The highest survey reading is 0.2 mR per hour. This does not exceed public dose limit or an exposure that would cause a 25 milllirem TEDE. It is not lost or stolen. The source activity is 0.64 mCi. The source is at the top of the dip tube in the normal operating position in a safe position. The tank is approximately 30 foot tall and 20 foot wide in which the tank and the fluid is shielding the low activity source. The source will not expose the workers. The tank and gauge are on the 3rd floor of the refinery and only RSO's and workers supervised by RSO are allowed in this area. The engineer tried to remove it from this position for a scheduled source change out, and it could not be removed. At present, without shutting the production line down which makes plastic, this could cause a revenue loss of millions of dollars to the company. In the opinion of the Mississippi Health Physicist, this is not reportable. It does not meet SA 300 reporting requirements. The RSO has agreed to perform surveys at shift change and report any changes. This event is closed. If any changes occur and are reported. The agency will meet reporting requirements. Notified R4DO (Groom) and NMSS Events (by email).

The following was received from the Texas Department of State Health Services (the Agency) via email: On September 17, 2021, the Agency was notified by the licensee that a Troxler 3411 moisture density gauge containing a 40 milliCurie americium - 241 source and an 8 milliCurie cesium - 137 source was damaged at a temporary job site. The licensee reported that while the gauge was sitting on the ground and not being used it was run over by a bulldozer, snapping the operating arm of the cesium source. The source was in the shielded position when the event occurred and a radiation survey of the gauge after the event verified it was still fully shielded. The licensee stated the gauge would be returned to its storage location and arrangements would be made to have the gauge disposed of. No individual received an exposure that exceeded any limit. Additional information will be provided as it is received in accordance with SA-300. Texas Incident No.: 9885

• * * UPDATE FROM ART TUCKER TO THOMAS HERRITY AT 11:23 ON 09/20/21 * * *

The following information was received via e-mail: Received pictures of the gauge. Pictures show the rod for the cesium source was bent. The dose rate meter appears to be reading 0.8 millirem per hour. Notified R4DO (YOUNG) and NMSS Events Notification group.