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. 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 | |
|---|---|
| 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 | |
Western Regional Medical Center with Agreement State | |
WEEKMONTHYEARENS 555732021-11-12T07:00:00012 November 2021 07:00:00
[Table view]Agreement State Medical Event - Underdosage Due to HDR Afterloader Malfunction 2021-11-12T07:00:00 | |