ENS Event | |
|---|---|
04:00 Jul 25, 2019 | |
| Title | Agreement State Report - Source Failed to Retract |
| Event Description | The following was received via e-mail:
On Thursday, July 25, 2019, the licensee called to report an equipment failure event where, during a cardiovascular brachytherapy treatment, the source failed to retract at the end of the treatment time due to a kink in the catheter line. The unit being used was a Best Vascular, Inc., A1000 Series using the Novoste Beta-Cath 3.5 Delivery System and a Sr-90 source with a source strength of 79.3 mCi. A service engineer for Best Vascular was present during the time of treatment and was able to unkink the catheter line allowing the source to fully retract into the unit. There was no harm to the patient and no overexposure occurred. Event Report No.: PA190017 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. |
| Where | |
|---|---|
| West Penn Allegheny Health Systems Inc Pittsburgh, Pennsylvania (NRC Region 1) | |
| License number: | PA-0031 |
| Organization: | Pa Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+34.57 h1.44 days <br />0.206 weeks <br />0.0474 months <br />) | |
| Opened: | Joshua Myers 14:34 Jul 26, 2019 |
| NRC Officer: | Jeffrey Whited |
| Last Updated: | Jul 26, 2019 |
| 54184 - NRC Website | |
West Penn Allegheny Health Systems Inc with Agreement State | |
WEEKMONTHYEARENS 541842019-07-25T04:00:00025 July 2019 04:00:00
[Table view]Agreement State Agreement State Report - Source Failed to Retract 2019-07-25T04:00:00 | |