ENS 56867

v t e ENS Event
06:00 Nov 20, 2023
Title	Equipment Failure
Event Description	The following information was provided by the Texas Department of State Health Services (the Department) via email: On November 21, 2023, the licensee's radiation safety officer notified the Department that on November 20, 2023, during an intravascular brachytherapy (IVB) procedure, the strontium-90 source train did not reach the dwell position within 15 seconds. When they attempted to retract the source, it would not retract into the fully shielded position in the device, but it was outside the patient. Following established procedures, the delivery system (catheter, source train, etc.) was removed from the patient and placed in the device's emergency box. There were no overexposures to the patient or staff. The licensee used a second device and completed the IVB procedure on the patient. After a short time, the licensee was able to return the source train to the fully shielded position in the device. The manufacturer's representative will be coming onsite to perform an evaluation. The licensee did observe what appeared to be a possible kink in the catheter. More information will be provided as it is obtained in accordance with SA-300. Device Information: Best Vascular Novoste IVB model A1000 Source Information: Source train of 16 strontium-90 sources, current total activity 35.9 millicuries. Texas Incident Number: 10067 Texas NMED Number: TX230053

ENS 56867 +/-
Where
The Methodist Hospital Houston, Texas (NRC Region 4)
License number:	L00457
Organization:	Texas Dept Of State Health Services
Reporting

Agreement State
Time - Person (Reporting Time:+31.67 h1.32 days <br />0.189 weeks <br />0.0434 months <br />)
Opened:	Karen Blanchard 13:40 Nov 21, 2023
NRC Officer:	Karen Cotton-Gross
Last Updated:	Nov 21, 2023
56867 - NRC Website
v • d • e

v t e Emergency Notification System
The Methodist Hospital with Agreement State
WEEKMONTHYEAR2025-12-09T06:00:00 [Table view]
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