ENS 54899
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ENS Event | ||
|---|---|---|
05:00 Sep 1, 2020 | ||
| Title | Agreement State Report - Underdose During Medical Treatment | |
| Event Description | The following information was received via e-mail from the Texas Department of State Health Services (the Agency):
On September 14, 2020, the Agency was notified by the licensee's radiation safety officer (RSO) that they had discovered a medical event [occurred September 1, 2020] involving a Varian high dose rate remote afterloader (HDR) unit had occurred. The RSO reported that a patient was to receive two boost treatments using the HDR unit. While setting up for the second treatment, the licensee noted the length of source catheter tube used in the first treatment was incorrect, therefore only part of the intended target was treated. The RSO stated the patient and physician were both notified of the event and that the current plan is to perform an additional treatment to the area that was under exposed in the first treatment. The RSO stated they did not expect any adverse effects to the patient. The Agency has requested additional information on the event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 9796 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 | |
|---|---|
| Texas Dept Of State Health Services Houston, Texas (NRC Region 4) | |
| License number: | L06439 |
| Organization: | Texas Dept Of State Health Services |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+343.13 h14.297 days <br />2.042 weeks <br />0.47 months <br />) | |
| Opened: | Art Tucker 12:08 Sep 15, 2020 |
| NRC Officer: | Brian P. Smith |
| Last Updated: | Sep 15, 2020 |
| 54899 - NRC Website | |
Texas Department of State Health Services with Agreement State | |||||||
ENS 548912020-09-08T05:00:0008 September 2020 05:00:00 Agreement State | Agreement State Report - Lost and Recovered Camera ENS 548862020-09-05T05:00:0005 September 2020 05:00:00 Agreement State | Agreement State Report - Gauge Damaged When Struck by Vehicle ENS 548992020-09-01T05:00:0001 September 2020 05:00:00 Agreement State | Agreement State Report - Underdose During Medical Treatment ENS 548722020-08-31T05:00:00031 August 2020 05:00:00 Agreement State | Agreement State Report- Shutter Stuck in Open Position ENS 548662020-08-29T14:00:00029 August 2020 14:00:00 Agreement State Agreement State Report - Stolen Vehicle with Moisture Density Gauge ENS 548652020-08-28T05:00:00028 August 2020 05:00:00 Agreement State ENS 548622020-08-26T05:00:00026 August 2020 05:00:00 Agreement State ENS 548572020-08-24T05:00:00024 August 2020 05:00:00 Agreement State Agreement State Report - Nuclear Gauge Shutter Stuck Open ENS 548512020-08-21T13:00:00021 August 2020 13:00:00 Agreement State | ENS 548372020-08-13T05:00:00013 August 2020 05:00:00 Agreement State ENS 548152020-08-03T05:00:0003 August 2020 05:00:00 Agreement State Agreement State Report - Patient Underdose ENS 548102020-08-01T17:00:0001 August 2020 17:00:00 Agreement State Agreement State Report - Lost Moisture Density Gauge ENS 548052020-07-29T05:00:00029 July 2020 05:00:00 Agreement State Agreement State Report - Stuck Shutters ENS 547552020-06-23T14:00:00023 June 2020 14:00:00 Agreement State Agreement State Report - High Dose Rate Tandem Applicator Broken During Treatment ENS 547442020-06-09T05:00:0009 June 2020 05:00:00 Agreement State Agreement State Report - Stuck Shutter ENS 547302020-05-29T04:00:00029 May 2020 04:00:00 Agreement State Agreement State Report - Loss of Control of Radioactive Material ENS 547232020-05-21T05:00:00021 May 2020 05:00:00 Agreement State Agreement State Report - Stolen Moisture Density Gauge ENS 547062020-05-10T05:00:00010 May 2020 05:00:00 Agreement State ENS 546982020-05-07T05:00:0007 May 2020 05:00:00 Agreement State Agreement State Report - Damaged Nuclear Gauge ENS 546672020-04-09T05:00:0009 April 2020 05:00:00 Agreement State Agreement State Report - Dose Not Delivered to the Correct Location During Brachytherapy Treatment ENS 546232020-03-27T05:00:00027 March 2020 05:00:00 Agreement State Agreement State Report - Underdose of Patient Medical Event ENS 545862020-03-16T05:00:00016 March 2020 05:00:00 Agreement State Agreement State Report - Radiography Source Guide Tube Damaged ENS 545852020-03-13T05:00:00013 March 2020 05:00:00 Agreement State Agreement State Report - Patient Underdose ENS 545792020-03-10T05:00:00010 March 2020 05:00:00 Agreement State Agreement State Report - Stuck Open Shutter ENS 545532020-03-01T06:00:0001 March 2020 06:00:00 Agreement State Agreement State Report - Loss of Control of Radioactive Material ENS 545402020-02-24T06:00:00024 February 2020 06:00:00 Agreement State Agreement State Report - Stolen Density Gauge ENS 546262020-02-24T05:00:00024 February 2020 05:00:00 Agreement State Agreement State Report - Lost Static Control Device ENS 545342020-02-19T06:00:00019 February 2020 06:00:00 Agreement State Agreement State Report - Underdose of Yttrium-90 During Treatment ENS 545212020-02-11T06:00:00011 February 2020 06:00:00 Agreement State Agreement State Report - Qsa Exposure Device Open Shutter and Cap ENS 545112020-02-04T06:00:0004 February 2020 06:00:00 Agreement State Agreement State Report - Brachytherapy Source Failed to Retract ENS 544992020-01-29T06:00:00029 January 2020 06:00:00 Agreement State Texas Agreement State Report - Contamination Event Resulting in Restricted Access ENS 544862020-01-21T06:00:00021 January 2020 06:00:00 Agreement State Texas Agreement State Report - Stolen Moisture Density Gauge ENS 544822020-01-15T06:00:00015 January 2020 06:00:00 Agreement State Agreement State Report - Radiography Camera Source Disconnect ENS 544752020-01-12T06:00:00012 January 2020 06:00:00 Agreement State Agreement State - Fixed Gauge Stuck Shutter ENS 544562019-12-20T06:00:00020 December 2019 06:00:00 Agreement State Agreement State Report - Three Gauge Shutters Inoperable ENS 530082017-10-10T16:35:00010 October 2017 16:35:00 Agreement State Alarm System Breach 2020-09-08T05:00:00 [Table view] | ||
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