ENS 54336

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v t e 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: Sr-90 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.

ENS 54336 +/-
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
v • d • e

v t e Emergency Notification System
Charlotte Mecklenburg with Agreement State
WEEKMONTHYEAR2019-10-16T04:00:00 [Table view]
[ENS list for Charlotte Mecklenburg]

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