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On October 28, 2004, during a routine insp … On October 28, 2004, during a routine inspection of the Licensee, an Agency inspector discovered equipment discrepancies involving a Nucletron Selectron Model 106 Low Dose Rate (LDR) therapy device that indicated equipment failures which had not been reported to this Agency. A series of eight equipment failures interrupted patient treatments between May 16, 2004 and June 4, 2004. Radiation doses for the patients were not ascertained. No patient was injured. The Licensee failed to report the failures to this Agency within 24-hours and in writing within 7-days. The Licensee failed to forward these discrepancies to its Radiation Safety Committee (RSC) for resolution. The Licensee failed to prepare written directives for any patient treated on the LDR therapy device. No doses were listed in the treatment plan or in the patient's record. The Licensee indicated that corrective action would be cessation of operation of the LDR therapy device.</br>Texas Incident No.: I-8179</br>* * * UPDATE FROM HANSON TO KNOKE AT 17:27 ON 12/13/05 * * * </br>The State provided the following information via email:</br>A letter was sent to the licensee on 9/14/05 from Robert Free (State) informing the licensee that Condition 21 on their Texas License L01837, required them to report as follows:</br>The licensee shall cease treatment of patients when any safety related system of a LDR device is found inoperative, to include the source drive mechanisms treatment timing system, safety interlocks and radiation field alarms. The licensee shall report to the Deputy Director, Emergency Response and Incident Investigation, any malfunction that requires the termination of patient treatments for more than 24 hours and submit a written report of the incident and corrective actions within seven calendar days.</br>The response letter from the licensee dated 10/04/05, stated that there were actually 5 events affecting a total of patients; on 3 of these events there were 2 patients being treated simultaneously with the same LDR machine. In each case the attending physician was either on the premises or notified immediately. The physician either deemed the treatment received was sufficient or the treatments were rescheduled, some within 3 hours.</br>It was discovered by the licensee that during the investigation of these events that severe thunderstorms preceded all LDR malfunctions. It was the conclusion that the LDR had functioned as designed by detecting the significant change in power & shut itself down. No misadministrations occurred.</br>The manufacturer replaced the column, interface board, printer mechanism and power supply. The LDR has not been used in the past 12 months. In August 2005 the decision was made to take the LDR machine out of service.</br>Notified R4DO (Johnson) and NMSS (Essig).ice.
Notified R4DO (Johnson) and NMSS (Essig).
18:00:00, 16 May 2004 +
41,189 +
14:21:00, 10 November 2004 +
18:00:00, 16 May 2004 +
On October 28, 2004, during a routine insp … On October 28, 2004, during a routine inspection of the Licensee, an Agency inspector discovered equipment discrepancies involving a Nucletron Selectron Model 106 Low Dose Rate (LDR) therapy device that indicated equipment failures which had not been reported to this Agency. A series of eight equipment failures interrupted patient treatments between May 16, 2004 and June 4, 2004. Radiation doses for the patients were not ascertained. No patient was injured. The Licensee failed to report the failures to this Agency within 24-hours and in writing within 7-days. The Licensee failed to forward these discrepancies to its Radiation Safety Committee (RSC) for resolution. The Licensee failed to prepare written directives for any patient treated on the LDR therapy device. No doses were listed in the treatment plan or in the patient's record. The Licensee indicated that corrective action would be cessation of operation of the LDR therapy device.</br>Texas Incident No.: I-8179</br>* * * UPDATE FROM HANSON TO KNOKE AT 17:27 ON 12/13/05 * * * </br>The State provided the following information via email:</br>A letter was sent to the licensee on 9/14/05 from Robert Free (State) informing the licensee that Condition 21 on their Texas License L01837, required them to report as follows:</br>The licensee shall cease treatment of patients when any safety related system of a LDR device is found inoperative, to include the source drive mechanisms treatment timing system, safety interlocks and radiation field alarms. The licensee shall report to the Deputy Director, Emergency Response and Incident Investigation, any malfunction that requires the termination of patient treatments for more than 24 hours and submit a written report of the incident and corrective actions within seven calendar days.</br>The response letter from the licensee dated 10/04/05, stated that there were actually 5 events affecting a total of patients; on 3 of these events there were 2 patients being treated simultaneously with the same LDR machine. In each case the attending physician was either on the premises or notified immediately. The physician either deemed the treatment received was sufficient or the treatments were rescheduled, some within 3 hours.</br>It was discovered by the licensee that during the investigation of these events that severe thunderstorms preceded all LDR malfunctions. It was the conclusion that the LDR had functioned as designed by detecting the significant change in power & shut itself down. No misadministrations occurred.</br>The manufacturer replaced the column, interface board, printer mechanism and power supply. The LDR has not been used in the past 12 months. In August 2005 the decision was made to take the LDR machine out of service.</br>Notified R4DO (Johnson) and NMSS (Essig).ice.
Notified R4DO (Johnson) and NMSS (Essig).
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00:00:00, 14 December 2005 +
L01837-000 +
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02:19:41, 2 March 2018 +
14:21:00, 10 November 2004 +
177.806 d (4,267.35 hours, 25.401 weeks, 5.845 months) +
18:00:00, 16 May 2004 +
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