ENS 57690
ENS Event | |
|---|---|
04:00 Apr 16, 2025 | |
| Title | Equipment Failure |
| Event Description | The following information was provided by the Pennsylvania Bureau of Radiation Protection (the Department) via email:
On April 16, 2025, the University of Pittsburgh informed the Department of an equipment failure event involving its microSelection HDR [high dose-rate] device. It is reportable under 10 CFR 30.50(b)(2). A patient was receiving an iridium-192 treatment using an Elekta, Inc. microSelectron HDR 106.990. During the treatment, a software error occurred, and the computer shut off. This stopped the treatment and retracted the source into the safe/shielded position. The Elekta service engineer was immediately contacted, and a system reboot was performed to bring the HDR machine and computer back to functional status. The authorized user decided to continue treatment with the service engineer remaining immediately available via telephone. After the treatment was resumed, the source was deployed (as verified by room radiation monitor, source indicator at machine console computer, and sound of source movement) but the computer screen did not indicate treatment in progress by visual display and again gave an error message (`software problem detected'). The authorized medical physicist pressed the emergency button and the source was retracted. Per the authorized user physician, the patient's treatment was terminated for the day. Elekta personnel arrived on 4/17/25 and created 1 GB [Gigabyte] space on the local drive for a temporary solution, then permitted UPMC IT [University of Pittsburgh Medical Center Information Technology] personnel to assist. The UPMC IT personnel came onsite and created 230 GB local drive space, which is confirmed to be enough for the long term. Elekta personnel did note that treatment volumes for this location (which require more memory) are exceptionally high compared to other Elekta brachytherapy clinics. The cause of this event was possibly a generic issue with insufficient storage space availability, the software error occurred during treatment and the treatment data was not able to be stored in the database, which led to failure. The Department will perform a reactive inspection. Pennsylvania Event Report Number: PA250006 |
| Where | |
|---|---|
| University Of Pittsburgh Pittsburgh, Pennsylvania (NRC Region 1) | |
| License number: | PA-0190 |
| Organization: | Pa Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+459.12 h19.13 days <br />2.733 weeks <br />0.629 months <br />) | |
| Opened: | John S. Chippo 07:07 May 5, 2025 |
| NRC Officer: | Karen Cotton |
| Last Updated: | May 5, 2025 |
| 57690 - NRC Website | |
University Of Pittsburgh with Agreement State | |
WEEKMONTHYEARENS 576702025-04-16T04:00:00016 April 2025 04:00:00
[Table view]Agreement State Medical Event ENS 576902025-04-16T04:00:00016 April 2025 04:00:00 Agreement State Equipment Failure ENS 567702023-09-28T04:00:00028 September 2023 04:00:00 Agreement State Agreement State - I-125 Seed Inadvertently Transected ENS 551392021-03-12T05:00:00012 March 2021 05:00:00 Agreement State Dose Received Was Less than Prescribed Dose ENS 515672015-11-20T05:00:00020 November 2015 05:00:00 Agreement State Agreement State Report - Lost Radioactive Seed ENS 482862012-09-06T04:00:0006 September 2012 04:00:00 Agreement State Agreement State Report - Yttrium-90 Microspheres Administered to the Wrong Treatment Site 2025-04-16T04:00:00 | |