ENS 56933

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v t e ENS Event
15:00 Jan 25, 2024
Title	Underdose Caused by Equipment Failure
Event Description	The following information was provided by the Wisconsin Radiation Protection Section via email: On January 25, 2024, the licensee reported a medical event at 1119 CST which had occurred the same day at 0900 CST, where the dose delivered for a single fraction differed from the prescribed dose by more than 50 percent. This event is also reportable as an equipment failure. A patient was being treated with a Nucletron Corporation Model 106.990 high dose rate remote after loader unit, and during the fraction, the physicist noticed that the timer on the console had frozen while the source remained exposed. The planned treatment time was 6 minutes and 15 seconds over 9 dwell positions, and the timer, counting down, was frozen at 6 minutes and 7 seconds. Once the freeze was noticed, the physicist pressed the emergency stop button on the console to terminate the treatment. The physicist estimated that the total treatment time was approximately 30-40 seconds, all of which was to the first dwell position. The authorized user had prescribed 550 cGy for this fraction and the physicist estimated that only 11 percent of the prescribed dose was delivered. The physicist reported that the timer functioned properly during the daily quality assurance checks prior to treatment. The patient and patient's family were notified by the authorized user. The licensee is contacting the device vendor for emergency service. Wisconsin Event Number: WI240001 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.

ENS 56933 +/-
Where
Uw Cancer Center At Prohealth Care Waukesha, Wisconsin (NRC Region 3)
License number:	133-1339-01
Organization:	Wisconsin Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+-0.38 h-0.0158 days <br />-0.00226 weeks <br />-5.20524e-4 months <br />)
Opened:	David Reindl 14:37 Jan 25, 2024
NRC Officer:	Adam Koziol
Last Updated:	Jan 25, 2024
56933 - NRC Website
v • d • e

v t e Emergency Notification System
Uw Cancer Center At Prohealth Care with Agreement State
WEEKMONTHYEAR2024-01-25T15:00:00 [Table view]
[ENS list for Uw Cancer Center At Prohealth Care]

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