ENS 49089
ENS Event | |
|---|---|
05:00 Jun 3, 2013 | |
| Title | Agreement State Report - Source Retraction Failure |
| Event Description | The following was received from the State of Texas via email:
On June 3, 2013, the Agency [State of Texas] was notified by the licensee that on June 3, 2013, a medical event had occurred. The licensee reported a source retraction failure with a Novoste Beta-Cath intravascular brachytherapy system containing a 45.1 mCi strontium - 90 source. When the treatment was completed, upon source retraction, the source got stuck in another area of the blood vessel roughly 5 cm away from the treatment site for 1 minute. The unintended absorbed dose to that area of the vessel is in the range of 5-6 Gy. The source open in air time was roughly 3 seconds from being retracted from the patient before being secured in a bail out box. Personnel exposure issues or concerns are not expected, however, dosimeters will be assessed. A technical representative was notified and during the next several days will inspect the system and assist in packaging the system for return shipment back to the manufacturer. Additional information will be provided as it is received in accordance with SA-300. 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 updated information was provided from the State of Texas via email: The Methodist Hospital reported an equipment failure that involved a source retraction during an intravascular brachytherapy treatment performed on 6/3/2013. The intravascular brachytherapy system (Best Vascular Beta-Cath A1000 series) contained a 1.67 GBq (45.1 mCi) Sr-90 source. When the treatment was completed and upon source retraction, the source became stuck in another area of the blood vessel approximately 5 cm from the treatment site for one minute. The unintended absorbed dose to the area of the aortic arch was approximately 40 cGy at 10 mm on the wall of the arch. A technical representative was notified and will inspect the system within the next several days and assist in packaging the system for return to the manufacturer. The State of Texas determined that this event is no longer classified a medical event and has been updated to equipment failure. Notified R4DO (Gepford) and FSME Events Resource email. Texas Incident #: I-9088 |
| Where | |
|---|---|
| The Methodist Hospital Texas (NRC Region 4) | |
| License number: | 00457 |
| Organization: | Texas Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+32.55 h1.356 days <br />0.194 weeks <br />0.0446 months <br />) | |
| Opened: | Chris Moore 13:33 Jun 4, 2013 |
| NRC Officer: | Charles Teal |
| Last Updated: | Jun 14, 2013 |
| 49089 - NRC Website | |
The Methodist Hospital with Agreement State | |
WEEKMONTHYEARENS 568672023-11-20T06:00:00020 November 2023 06:00:00
[Table view]Agreement State Equipment Failure ENS 552222021-04-28T06:00:00028 April 2021 06:00:00 Agreement State Medical Event ENS 550332020-12-11T06:00:00011 December 2020 06:00:00 Agreement State Unretractable Source ENS 490892013-06-03T05:00:0003 June 2013 05:00:00 Agreement State Agreement State Report - Source Retraction Failure ENS 486402012-12-04T06:00:0004 December 2012 06:00:00 Agreement State Therapy Source Jammed at the Device Entry Port ENS 479522012-04-10T05:00:00010 April 2012 05:00:00 Agreement State Agreement State Report - Stuck Source in Catheter ENS 457082008-12-10T06:00:00010 December 2008 06:00:00 Agreement State Agreement State Report - Source Stuck in Catheter Tube ENS 409672004-07-28T05:00:00028 July 2004 05:00:00 Agreement State Source Train Did Not Retract ENS 404302004-01-05T14:16:0005 January 2004 14:16:00 Agreement State Agreement State Report: Novoste Strontium-90 Intravasular Brachytherapy (Ivb) Source Discovered Missing. 2023-11-20T06:00:00 | |