ENS Event | |
|---|---|
06:00 Dec 12, 2022 | |
| Title | Equipment Failure to House Source |
| Event Description | The following information was provided by the Texas Department of State Health Services via email:
On December 12, 2022, the licensee reported that following a cardiac brachytherapy procedure the source train containing strontium-90 sources could not be fully retracted into the safe position. The device was placed into the emergency shielding box by a staff member. There was no exposure to the patient and there was no overexposure, based on calculations, to the individual who handled the device. The individual's ring and whole body dosimeters will be sent for processing to confirm. A manufacturer's representative responded later in the day and secured the sources into the fully shielded position and assessed the cause. He believed the hemostasis valve had been tightened a little too tight which caused a kink in the catheter that prevented the retraction. Device: Novoste Brachytherapy device manufactured by Best Vascular, model A-1000 series, SN: 87690 Sources: 40 millimeter source train containing 16 Strontium-90 sealed sources with original activity of 34.88 millicuries (June 2002), source manufacturer AEA, model SICW.2, train SN: ZA-706. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300. Texas Incident No.: 9971 Texas NMED No.: TX220040 |
| Where | |
|---|---|
| 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:+31.17 h1.299 days <br />0.186 weeks <br />0.0427 months <br />) | |
| Opened: | Karen Blanchard 13:10 Dec 13, 2022 |
| NRC Officer: | Adam Koziol |
| Last Updated: | Dec 13, 2022 |
| 56270 - NRC Website | |
Methodist Hospital with Agreement State | |
WEEKMONTHYEARENS 562702022-12-12T06:00:00012 December 2022 06:00:00
[Table view]Agreement State Equipment Failure to House Source 2022-12-12T06:00:00 | |