ENS 41008

v t e ENS Event
19:00 Aug 31, 2004
Title	Wisconsin Agreement State Report: Source Failed to Retract
Event Description	On the evening of August 31, 2004 during a mammosite treatment utilizing a Varian HDR unit, the source failed to retract upon completion of the treatment time. The licensee's RSO/AMP had to enter the treatment room and retract the source manually. The licensee subsequently contacted Varian for assistance. A service representative from Varian arrived at Aurora Baycare Medical Center on Wednesday, Sept. 1, 2004. The Varian service representative found nothing wrong with the HDR unit. However, approximately 2 cm of the connecting catheter had 'buckled' (appeared melted and twisted), possibly restricting source movement. The licensee has contacted the catheter manufacturer for assistance in analyzing the catheter to determine what may have caused it to buckle. Preliminary dose indications by the licensee indicate that the patient received an additional amount of dose to the skin while the source was being retracted. The licensee reported that the most probable estimate of the additional skin dose is 1.0 Gy.

ENS 41008 +/-
Where
Aurora Baycare Medical Center Aurora, Wisconsin (NRC Region 3)
License number:	09-1017-01
Organization:	Wisconsin Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+40.33 h1.68 days <br />0.24 weeks <br />0.0552 months <br />)
Opened:	Paul Caleb 11:20 Sep 2, 2004
NRC Officer:	John Mackinnon
Last Updated:	Sep 2, 2004
41008 - NRC Website
v • d • e

v t e Emergency Notification System
Aurora Baycare Medical Center with Agreement State
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