ENS 54448
ENS Event | |
|---|---|
05:00 Dec 13, 2019 | |
| Title | |
| Event Description | EN Revision Imported Date : 1/10/2020
AGREEMENT STATE REPORT - HIGH DOSE RATE APPLICATOR DISLODGED The following was received from the PA Department Bureau of Radiation Protection (DEP) via fax: On December 16, 2019, the medical physicist for the licensee verbally reported that during an HDR [high dose rate] treatment using a Varian Model VariSource IX with a Tandem & Ovoid applicator, the applicator was found dislodged at the end of the treatment period. This was fraction 4 of 5 planned fractions. It is unknown at this time how long the applicator was not in the planned position or what caused it to move. The prescribed dose was 600 cGy from a 5.126 Ci Iridium-192 source. No further information is available at this time. The DEP will update this event as soon as more information is provided. Event Report ID No: PA190029 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 information was received from the Agreement State via fax: The patient was seen on 12/27/2019, 12/30/2019, and 1/6/2020 for follow-up appointments. Observed skin effects were described as 'moist desquamation' due to the applicator being dislodged from the vaginal canal and positioned against the skin. The patient is being treated with Silvadene topical cream and will be followed up with regular skin checks. Based on the evidence observed, the licensee assumes that the applicator was against the skin long enough to deliver a skin dose in the range of 10-30 Gy. This dose makes the event a potential Abnormal Occurrence. The Department has performed a reactive inspection and continues to investigate the event. Notified R1DO (Schroeder) and NMSS group (via e-mail). |
| Where | |
|---|---|
| Pa Bureau Of Radiation Protection State College, Pennsylvania (NRC Region 1) | |
| License number: | PA-0126 |
| Organization: | Pa Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+101.73 h4.239 days <br />0.606 weeks <br />0.139 months <br />) | |
| Opened: | John Chippo 10:44 Dec 17, 2019 |
| NRC Officer: | Caty Nolan |
| Last Updated: | Jan 9, 2020 |
| 54448 - NRC Website | |
Pennsylvania Bureau of Radiation Protection with Agreement State | |||
| Agreement State Report - Recovered Miscellaneous Radioactive Items ENS 549112020-08-24T04:00:00024 August 2020 04:00:00 Agreement State | Agreement State Report - Stuck Shutter ENS 548352020-08-11T04:00:00011 August 2020 04:00:00 Agreement State Agreement State Report - Patient Underdose ENS 547052020-05-11T04:00:00011 May 2020 04:00:00 Agreement State Agreement State Report - Radiation Level on Package Exceeds Dot Limits ENS 546962020-05-05T04:00:0005 May 2020 04:00:00 Agreement State Agreement State Report - Medical Event ENS 546792020-04-05T04:00:0005 April 2020 04:00:00 Agreement State Agreement State Report - Stuck Shutter on Berthold Radioactive Gauge ENS 546412020-04-03T04:00:0003 April 2020 04:00:00 Agreement State Agreement State Report - Patient Underdose ENS 545422020-02-20T05:00:00020 February 2020 05:00:00 Agreement State Agreement State Report - Gauge Failure ENS 544972020-01-29T05:00:00029 January 2020 05:00:00 Agreement State Agreement State Report - Stolen Nuclear Density Gauge ENS 544482019-12-13T05:00:00013 December 2019 05:00:00 Agreement State ENS 442862008-06-11T04:00:00011 June 2008 04:00:00 Agreement State Agreement State Report - Recovered Nuclear Material 2020-09-28T04:00:00 [Table view] | ||