ENS 53250

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v t e ENS Event
06:00 Mar 2, 2018
Title	Agreement State Report - Equipment Malfunction
Event Description	The following was received from the State of Texas via email: On March 7, 2018 Agency [Texas Department of State Health Services] received notification that a Novoste device jammed with no exposure consequence to the patient. Licensee stated two attempts to complete the therapy procedure had taken place, there was no dose to the patient that would be classified as a medical event. The initial attempt with a beta-rail catheter was not successfully completed. The source train (16, Sr 90) did not move along the beta-rail catheter as expected, the source train was not retracted back into the device robotically. The source train in the Novoste device failed to go into the expected treatment position and stayed in the robotic interventional cardiology device for about 1.5 minutes during the intravascular brachytherapy procedure. The interventional catheter with the indicator source train was removed by the doctor (which he wasn't supposed to do). When the train could not be robotically remove back into the device through the beta rail catheter, the source removal from the patient had to be done manually. The source train was retrieved in 15 seconds and placed back into the Novoste device. The treatment was stopped. The patient was surveyed to confirm no sources in the patient. It was believed the beta catheter developed a kink and could not retract the sources. The second attempt was with a new beta rail catheter and source reset. The treatment continued without any incidents. The source returned to the device without any problems. Incident # 9552

ENS 53250 +/-
Where
Houston Methodist Houston, Texas (NRC Region 4)
License number:	00457
Organization:	Texas Dept Of State Health Services
Reporting

Agreement State
Time - Person (Reporting Time:+131.33 h5.472 days <br />0.782 weeks <br />0.18 months <br />)
Opened:	Irene Casares 17:20 Mar 7, 2018
NRC Officer:	Steven Vitto
Last Updated:	Mar 7, 2018
53250 - NRC Website
v • d • e

v t e Emergency Notification System
Houston Methodist with Agreement State
WEEKMONTHYEAR2018-03-02T06:00:00 [Table view]
[ENS list for Houston Methodist]

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