ENS Event | |
|---|---|
04:00 Oct 16, 2019 | |
| Title | Agreement State Report - Medical Event |
| Event Description | The following is the summary of an email received from the state of North Carolina:
A patient was scheduled for an intravascular brachytherapy treatment on 10/16/2019. The treatment utilized a Novoste transfer device with an Sr-90 source. The prescribed dose for the treatment was 23.0 Gy, which corresponds to a planned treatment time of 5 minutes and 47 seconds. The treatment was delivered and the source return process was initiated. Resistance was encountered returning the source to the transfer device and the team had to commence the emergency bail-out procedure. The catheter was extracted while it was still attached to the device and both were placed in the bail-out box. The patient, room, and box were all surveyed. The survey confirmed that the source was in the bail-out box. The box was then transferred to a designated secure location. Because of the additional time elapsed between the expected return of the source to the transfer device and the securing of the source in the bail-out box it is possible that the patient could have received an additional dose of up to 6.98 Gy. The manufacturer of the transfer device was notified of this event on 10/16/2019. The patient and referring physician were both notified on 10/17/2019. Device Information: Transfer Device Manufacturer: Novoste (Best Medical) Model: Beta Cath System Serial: 91806 Source Information: Manufacturer: Novoste Activity: 2.01 GBq (4/16/03) Serial: ZB607 NC Tracking Number: NC 190036 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 | |
|---|---|
| Charlotte Mecklenburg Charlotte, North Carolina (NRC Region 1) | |
| License number: | 060-0014-3 |
| Organization: | Nc Div Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+36.93 h1.539 days <br />0.22 weeks <br />0.0506 months <br />) | |
| Opened: | Travis Cartoski 16:56 Oct 17, 2019 |
| NRC Officer: | Andrew Waugh |
| Last Updated: | Oct 17, 2019 |
| 54336 - NRC Website | |
Charlotte Mecklenburg with Agreement State | |
WEEKMONTHYEARENS 543362019-10-16T04:00:00016 October 2019 04:00:00
[Table view]Agreement State Agreement State Report - Medical Event 2019-10-16T04:00:00 | |