ENS 55222

v t e ENS Event
06:00 Apr 28, 2021
Title	Medical Event
Event Description	The following was received via e-mail from the Texas Department of State Health Services: The licensee reported that on April 28, 2021, a medical event involving a High Dose Rate (HDR) afterloader gynocological treatment, using a Varian VariSource iX device, with an iridium-192 sealed source of 6.93 curies, at the time of treatment, had occurred at is facility. The wrong length transfer tube was used which resulted in a dose of 600 centigray, the intended dose fraction, to an area, mostly skin, approximately 12 centimeters from the intended treatment site. The authorized user does not expect any harm to the patient. The patient has been informed. More information will be provided as it is obtained in accordance with SA-300. Texas Incident Number: 9843 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 55222 +/-
Where
The Methodist Hospital Houston, Texas (NRC Region 4)
License number:	L 00457
Organization:	Texas Dept Of State Health Services
Reporting

Agreement State
Time - Person (Reporting Time:+35.65 h1.485 days <br />0.212 weeks <br />0.0488 months <br />)
Opened:	Karen Blanchard 17:39 Apr 29, 2021
NRC Officer:	Joanna Bridge
Last Updated:	Apr 29, 2021
55222 - NRC Website
v • d • e

v t e Emergency Notification System
The Methodist Hospital with Agreement State
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