ENS 54696
ENS Event | |
|---|---|
04:00 May 5, 2020 | |
| Title | Agreement State Report - Medical Event |
| Event Description | The following information was received via email:
The Department [Pennsylvania Bureau of Radiation Protection] received notification from a licensee on May 5, 2020, of a medical event involving a Varian GammMedplus iX high dose rate remote afterloader (HDR) containing 8.6 Ci of iridium 192. The patient was set to receive 10 fractions (channels) of breast cancer treatment. An error was noted when treatment from the third channel was attempted. The source was retracted back into the safe position upon the error indication. Staff reset the unit and rebooted. The unit functioned normally for the fourth channel. During the fifth channel the machine experienced another fault, but the source did not automatically retract. Staff then attempted two emergency stop procedures; however, both failed. Staff were finally able to manually retract the source after approximately two to four minutes; however, it hasn't been determined if the source was completely retracted into the shielded safe on the HDR due to catheter interference. The patient was quickly disconnected from the catheter, everyone was immediately removed, and the room was secured from entry. No dose is expected outside the HDR room as it is housed within an accelerator vault. The manufacturer has been contacted. The licensee has also requested the log files from the manufacturer for dose reconstruction of those involved. The department is currently in contact with the licensee and will update this event as soon as more information is provided. PA Event Report ID No: PA200011
The following information was received via email: Manufacturer service technicians removed the wire/source from the afterloader on 5/6/2020. Preliminarily, it appears the source became stuck approximately 4 to 5 inches from the shielded park position (inside the afterloader, but outside the shielded safe). Dosimetry badges have been sent for emergency read, results are expected today, and those results are expected to be minimal. The patient and all personnel involved were surveyed after the incident and readings were at background levels. Notified R1DO (Dentel) and NMSS Event Notifications (email).
The following information was received via email: The preliminary dosimetry report indicates three staff members involved in the event. The technologist received 4 mrem whole body dose, the authorized user received 3 mrem whole body dose and the AMP received 3 mrem whole body dose and a 15 mrem dose on their finger dosimeter. No other dose information was received at this time. Notified R1DO (Lally) and NMSS Event Notifications (email). 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 | |
|---|---|
| Pa Bureau Of Radiation Protection Mechanicsburg, Pennsylvania (NRC Region 1) | |
| License number: | PA-0249 |
| Organization: | Pa Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+32.72 h1.363 days <br />0.195 weeks <br />0.0448 months <br />) | |
| Opened: | John Chippo 12:43 May 6, 2020 |
| NRC Officer: | Andrew Waugh |
| Last Updated: | May 12, 2020 |
| 54696 - 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] | ||