ENS 45708

v t e ENS Event
06:00 Dec 10, 2008
Title	Agreement State Report - Source Stuck in Catheter Tube
Event Description	The following information was obtained from NMED: The Methodist Hospital reported that a 1.91 GBq (51.57 mCi) Sr-90 source (BEBIG model Sr0.S03, serial #ZB523) became stuck in a catheter during a patient's treatment on 12/10/2008, using a Novoste Beta-Cath system (model A1732, serial 91277). The catheter was removed from the patient and placed into a bailout box. The bailout box was returned to storage and additional shielding was used to ensure dose rates in the area were ALARA. There was no additional exposure to any individual involved. A preliminary visual inspection of the device indicated that there may be a small kink in the capillary tube, which prevented the source from returning to its secured location. The source was returned to the manufacturer for further investigation. The manufacturer determined that the source became stuck due to kinks in the delivery catheter. They provided additional guidance to the hospital in the use of the system to help minimize recurrence. The State of Texas discovered that the event was reported to NMED but not to the NRC Headquarters Operations Center as required therefore they are making a late report. Texas Report Number: I-8590

ENS 45708 +/-
Where
The Methodist Hospital Houston, Texas (NRC Region 4)
License number:	L-00457
Organization:	Texas Department Of Health
Reporting

Agreement State
Time - Person (Reporting Time:+10444.97 h435.207 days <br />62.172 weeks <br />14.308 months <br />)
Opened:	Art Tucker 10:58 Feb 18, 2010
NRC Officer:	Howie Crouch
Last Updated:	Feb 18, 2010
45708 - NRC Website
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v t e Emergency Notification System
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