ENS 44397

v t e ENS Event
18:00 Aug 7, 2008
Title	Agreement State Report - Underexposure During Hdr Medical Treatment Due to Equipment Malfunction
Event Description	The State received notification of a possible medical event due to an equipment malfunction. The licensee was treating a patient for rectal cancer using an HDR Nucleotron Micro Select Model 105.999 Serial 31776. The prescribed treatment consisted of the administration of 29 catheter doses of Iridium-192. During the 12th catheter dose, an equipment malfunction caused a failure of the administered treatment. The failure mode was Code 200 - "No radiation detected." The failure mode caused the unit to stop treatment by not proceeding to the next catheter. Nucleotron immediately contacted. A service technician is expected to arrive on 8/8/08 for repair of the device. Once the HDR unit is repaired, the treatment plan and written directive will be modified and treatment of the patient resumed. Patient and physician have been advised of the treatment interruption and no adverse impact is expected. The State of Ohio plans to send an inspector to the facility on 8/11/08. 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.

ENS 44397 +/-
Where
Cleveland Clinic Foundation Cleveland, Ohio (NRC Region 3)
License number:	02110-18-0013
Organization:	Ohio Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+17.48 h0.728 days <br />0.104 weeks <br />0.0239 months <br />)
Opened:	Mark Light 11:29 Aug 8, 2008
NRC Officer:	Bill Huffman
Last Updated:	Aug 8, 2008
44397 - NRC Website
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Cleveland Clinic Foundation with Agreement State
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