The following report was received by the
Pennsylvania Bureau of Radiation Protection [the Department] via email:
On April 16, 2025, a patient was receiving an iridium-192 treatment using an Elekta, Inc. microSelectron HDR [high-dose remote afterloader]. During the procedure, a software error that retracted the source occurred. The unit was rebooted, and the treatment was restarted. However, 17 seconds into restarting, the unit failed to show the next dwell position, so the treatment was terminated. Approximately 48 percent of the prescribed dose was administered to the patient. No harm is expected to the patient and both the physician and patient were notified. The patient treatment plan will be updated accordingly.
The official cause is still under investigation. The service engineer will be onsite April 17, 2025, to troubleshoot the HDR. The Department will perform a reactive inspection. More information will be provided as received.
Pennsylvania Event Report Number: PA250004
- * * RETRACTION ON 04/29/2025 AT 1254 EDT FROM JOHN S. CHIPPO TO TROY JOHNSON * * *
The following report was received by the Pennsylvania Bureau of Radiation Protection via email:
On April 16, 2025, a patient was receiving an iridium-192 treatment using an Elekta, Inc. microSelectron HDR 106.990 [high-dose remote afterloader]. Initially, it was reported that they received 48 percent of the fractionated dose prescribed, however, an Elekta service engineer was onsite on April 17, 2025, to troubleshoot the HDR. They determined that, based on the true delivery time, verified via machine detailed logfiles, the patient received 73 percent of the planned treatment dose during this fraction (the patient was prescribed 7.0 Gy and received 5.1 Gy). Since the patient dose for this fraction delivered did not differ from the prescribed dose by 50 percent or more, this event does not meet the qualifications for reporting.
Notified R1DO (Lally), and NMSS Events Notification (email)
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.