ENS Event | |
|---|---|
05:00 Nov 24, 2021 | |
| Title | Brachytherapy Source Position Error |
| Event Description | The following was received from the Virginia Department of Health, Radioactive Materials Program (the agency) via email:
On November 24, 2021, the agency was notified by the [radiation safety officer] at the University of Virginia, by email at 1347 EST and by phone at 1355 EST, that a medical event involving an HDR [high dose rate brachytherapy] had occurred that day. During a prostate HDR Iridium-192 case, the patient was treated without any issues through the first channel. At the start of the second channel run, an error was received indicating that the source position slipped while at the 0.0 cm mark. The procedure was paused with no treatment to the patient through the second channel. A dummy wire test was run with no errors indicated. A second attempt at treatment with the source through the second channel was made and the same position error was indicated. The treatment was cancelled at that point. Having only received the first channel treatment, the patient received less than 5 percent of the total prescribed dose. The HDR unit is a Varian VariSource iX, serial number V3509. The source is an Alpha Omega Iridium-192, serial number 02-01-3798-001-191421-11617-25 with a current activity of 5.98 Ci. The licensee contacted Varian and stated that they believe it is likely an issue with the afterloader itself. The source was verified to be in the unit and no additional exposure to the patient or staff was received from the event. The licensee is working with Varian to schedule a repair visit. This report will be updated when the licensee submits their final investigation report. Virginia Event Report ID No.: VA-21-0007 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 | |
|---|---|
| University of Virginia Charlottesville, Virginia (NRC Region 1) | |
| License number: | 540-248-1 |
| Organization: | Virginia Rad Materials Program |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+125.4 h5.225 days <br />0.746 weeks <br />0.172 months <br />) | |
| Opened: | Sheila Nelson 10:24 Nov 29, 2021 |
| NRC Officer: | Mike Stafford |
| Last Updated: | Nov 29, 2021 |
| 55613 - NRC Website
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University of Virginia with Agreement State | |
WEEKMONTHYEARENS 556132021-11-24T05:00:00024 November 2021 05:00:00
[Table view]Agreement State Brachytherapy Source Position Error ENS 551972021-04-15T04:00:00015 April 2021 04:00:00 Agreement State Lost Tritum Exit Sign ENS 543972019-11-19T05:00:00019 November 2019 05:00:00 Agreement State Agreement State Report - Dose Less than Prescribed Delivered to Treatment Site ENS 504332014-09-04T04:00:0004 September 2014 04:00:00 Agreement State Agreement State Report - Medical Event Due to Misadministration of Y-90 Theraspheres 2021-04-15T04:00:00 | |