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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 48813 | 7 March 2013 05:00:00 | Agreement State | Agreement State Report - Medical Underdose Due to Equipment Failure | A patient was treated with a Varian GammaMed plus iX HDR unit on March 7, 2013. The prescription dose was 700 cGy per fraction for 2 fractions, with a prescription dose of 800 cGy for a third fraction. The first two fractions were delivered to the patient as planned, the first fraction on February 26, 2013 and the second on February 28, 2013. The third fraction was to be delivered via tandem and ovoid. The planned tandem dose of 613 cGy was successfully delivered, and the source returned to its shielded position. However, prior to delivery of the ovoid dose of 187 cGy, the HDR unit displayed an error message of 'Electronics Defective error.' The staff could not correct the error. The manufacturer was notified and a service technician arrived later in the day to correct the problem. The remaining portion of the fraction was cancelled for the day and re-scheduled. The fractionated dose delivered differed from the prescribed fraction by 23.37%. The Varian service technician arrived later in the day and replaced the unit's indexer board, cleaned the indexer belt, tested a spring for tightness and re-set the wheel on the belt. The unit then functioned properly. 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. |