ENS 55573

v t e ENS Event
07:00 Nov 12, 2021
Title	Medical Event - Underdosage Due to HDR Afterloader Malfunction
Event Description	The following information was received via E-mail: On November 12, 2021, the Department (Arizona Department of Health Services) was notified by the licensee that during an HDR treatment, an error message showed up after the first 15 channels were delivered. The error message was '8C:2 Dummy park switch or drive failure.' The Varian Medical System help desk was contacted for the error message without resolution. The field service engineer was called and suggested to power down the afterloader unit and reboot it, which did not resolve the problem. To avoid putting the patient under general anesthesia any longer, the Authorized User decided to stop the treatment and left the remaining four (4) channels untreated. The prescribed dose was 14 Gy and the estimated dose given was 10.2 Gy. The afterloader unit was a Varian Varisource iX, with an activity of 7.5 Ci of Iridium-192. The Department has requested additional information and continues to investigate the event. Arizona Incident: 21-010 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 55573 +/-
Where
Western Regional Medical Center Goodyear, Arizona (NRC Region 4)
License number:	07-629
Organization:	Arizona Dept Of Health Services
Reporting

Agreement State
Time - Person (Reporting Time:+12.13 h0.505 days <br />0.0722 weeks <br />0.0166 months <br />)
Opened:	Brian Goretzki 19:08 Nov 12, 2021
NRC Officer:	Donald Norwood
Last Updated:	Nov 12, 2021
55573 - NRC Website
v • d • e

v t e Emergency Notification System
Western Regional Medical Center with Agreement State
WEEKMONTHYEAR2021-11-12T07:00:00 [Table view]
[ENS list for Western Regional Medical Center]

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