ENS Event | |
|---|---|
06:00 Nov 8, 2023 | |
| Title | Agreement State - Door Interlock Failure |
| Event Description | The following information was provided by the Wisconsin Department of Health Services (the Department) email:
On Wednesday, November 8, 2023, the licensee was treating an individual in their high dose rate (HDR) suite. During the treatment, while the Ir-192 source was exposed, it was noticed that the door to the suite was ajar. The treatment was immediately paused, and the physicist confirmed that the door was open and that the door interlock was not functioning as required. The staff closed the door, put up caution tape, and maintained constant visual surveillance to ensure no one entered. Treatment was reinitiated and completed according to the written directive. On Friday, November 10, 2023, the interlock had not yet been repaired, and the licensee performed another HDR treatment utilizing caution tape and constant surveillance. The licensee reported the event to the Department by phone on November 14, 2023. The licensee performed an event reconstruction and surveyed at the open door with the Ir-192 source exposed. The highest dose rate of 0.3 mR/hr indicates that no member of the public would have received a dose exceeding public dose limits from this event. The patients were unaffected. The Department will be performing a reactive inspection on November 20, 2023. WI Event Report ID Number: WI230022 |
| Where | |
|---|---|
| Aspirus-Wausau Hospital Wausau, Wisconsin (NRC Region 3) | |
| License number: | 073-1342-01 |
| Organization: | Wisconsin Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+176.32 h7.347 days <br />1.05 weeks <br />0.242 months <br />) | |
| Opened: | Kyle Walton 14:19 Nov 15, 2023 |
| NRC Officer: | Ernest West |
| Last Updated: | Nov 15, 2023 |
| 56854 - NRC Website | |
Aspirus-Wausau Hospital with Agreement State | |
WEEKMONTHYEARENS 568542023-11-08T06:00:0008 November 2023 06:00:00
[Table view]Agreement State Agreement State - Door Interlock Failure ENS 531682018-01-05T06:00:0005 January 2018 06:00:00 Agreement State Agreement State Report - Delivered Dosage Different from Prescribed ENS 531482018-01-04T06:00:0004 January 2018 06:00:00 Agreement State Agreement State Report - Delivered Dosage Different from Prescribed ENS 530092017-08-11T05:00:00011 August 2017 05:00:00 Agreement State Agreement State Report - Medical Underdose ENS 526292016-12-09T05:00:0009 December 2016 05:00:00 Agreement State Agreement State Report - Total Dose Less than 80 Percent of Prescribed Dose ENS 520352016-06-17T05:00:00017 June 2016 05:00:00 Agreement State Agreement State Report - Contamination of Brachytherapy Patient 2023-11-08T06:00:00 | |