Semantic search
| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 47340 | 12 October 2011 19:30:00 | Agreement State | Agreement State Report - Malfunction of Irradiator Source Drive Mechanism | The following information was received from the Texas Dept of Health Services Investigation Unit Radiation Branch via email: On October 12, 2011, at 1552 hours CDT, the Agency was notified by the licensee's Radiation Safety Officer (RSO) that there had been a malfunction identified with (a self contained) irradiator, at the licensee's facility in Houston, Texas. The source was, and had been, in the fully shielded position and therefore did not present a risk of exposure to any individual. The owner/operator within the facility reported to the RSO's staff that the compressor failed on Friday, October 7, 2011, and they were going to get it repaired or replaced. While working to replace/repair the compressor, it was determined that the problem was not the compressor. The licensee was able to open and close the door to the irradiation chamber and apparently make up all the interlocks, but the source failed to move. Finally, it was determined on Wednesday, October 12th at approximately 1430 hrs that the source drive mechanism was failing to move the source. The owner/operator has been in contact with Shepherd to make arrangements for repair. More information will be provided as it is obtained. The irradiator has been posted as out of service. The source is properly shielded as shown by dose rate surveys conducted in the room. Texas Incident Number: I-8892 | ||
| ENS 47266 | 9 September 2011 23:00:00 | Agreement State | Agreement State Report Involving a Less than Prescribed Dose Administration | The following information was received from the State of Texas via email: On September 13, 2011, the Agency was notified by the licensee that it had determined that a medical event had occurred at its facility. The licensee reported that on Friday, September 9, 2011, a patient had undergone a therapy procedure at approximately 3:00 p.m. which involved insertion of Yttrium-90 TheraSpheres into the liver. The patient's prescribed dose was to be 80 gray. Following the procedure, the technician took measurements, as part of the standard operating procedures, of the vial and other items associated with the treatment. The technician found that the dose rate was higher than would be expected if all of the contents of the vial had been delivered. The technician notified the medical physicist and they discussed the measurements. At approximately 6:00 p.m. they determined that an underdose had most likely occurred, but they were not yet sure it was a medical event. On Monday, September 12th, evaluation and measurements were conducted on the vial and dose calculations were completed. On Monday afternoon, it was determined that the patient had received a dose of 49 gray (22.3 millicuries administered), which is 39% less than the prescribed dose of 80 gray (37 millicuries). A meeting was arranged with the facility's Radiation Safety Officer on Tuesday, September 13th, at which time he was advised of the findings. Initial investigation by the licensee indicated some type of failure of the septum on the TheraSphere vial had occurred. The licensee will complete their investigation and submit a written report. An update to this report will be provided when new information is received. Texas Incident No.: I-8883 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 44460 | 15 August 2008 05:00:00 | Agreement State | Agreement State Report - Irradiator Crank Mechanism Failure | On 9/2/08 at 16:30, the (Texas Department of State Health Services) received a letter from the licensee stating that on 8/15/08, they were unable to move the source head on a U.S. Nuclear Model E-0103 Irradiator. The device contains a Cesium (Cs) - 137 source with an estimated activity of 2251 curies and is used in research irradiation of in vitro samples. The source is fully shielded. Dose rates and contamination surveys conducted on the source head were normal. The unit has been taken out of service awaiting repairs. TX Incident # I-8547
The RSO called at 1444 and stated that he had some corrected information. He stated that the device contained two 2660 curie Cs 137 sources installed in 1975 and manufactured on 2/15/68 making the current activity 1045 curies each. He stated that the device had been repaired, but was still trying to find out when. Notified R4DO(Jones), FSME(Turtil). |