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The following information was received fro … The following information was received from the State of New Jersey:</br>A patient was treated with a Nucletron microSelectron 106.990(v3) HDR unit on March 12, 2012. The prescription dose was 600 cGy per fraction for 5 fractions. The fractional treatment planned was for a total of 14 dwell positions in two different catheters: six dwell positions in the ring to be treated on HDR Channel 1 and eight dwell positions in the tandem to be treated on HDR Channel 3. After all appropriate QA, the patient treatment was started with Channel 1 being the first set of dwell positions treated. At the completion of the Channel 1 treatment, the HDR unit gave an error stating that there was a 'Possible incomplete source retraction in Channel 2.' Even though all radiation indicators did not detect the presence of radiation, and even though the licensee was not using Channel 2, immediate emergency procedures were implemented. The emergency stop was activated and the room was entered with a survey meter to verify that there was no elevated radiation present. All indications were that the source was retracted properly and that there was no danger to the patient or the staff.</br>The error displayed on the treatment screen indicated that it was possible that dust was on the optocoupler, thus causing the fault. However, the error could not be cleared by using the reset button. Nucletron was immediately contacted. Nucletron support personnel attempted to walk the licensee through some steps that may have cleared the error, but they were unsuccessful. Therefore, the remaining part of the patient's treatment was aborted. Nucletron scheduled one of their service engineers to respond to the licensee's facility to repair the unit.</br>The authorized user informed the patient that the complete treatment was not delivered due to the machine malfunction and that the authorized user would determine what action to take on the future fractions. The patient and the treatment room were surveyed prior to release. No elevated readings were observed. The patient received 120 cGy (versus the prescribed dose of 600 cGy). The deviation from the written directive was documented in the patient's chart.</br>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.necessarily result in harm to the patient.
04:00:00, 12 March 2012 +
47,737 +
11:22:00, 13 March 2012 +
04:00:00, 12 March 2012 +
The following information was received fro … The following information was received from the State of New Jersey:</br>A patient was treated with a Nucletron microSelectron 106.990(v3) HDR unit on March 12, 2012. The prescription dose was 600 cGy per fraction for 5 fractions. The fractional treatment planned was for a total of 14 dwell positions in two different catheters: six dwell positions in the ring to be treated on HDR Channel 1 and eight dwell positions in the tandem to be treated on HDR Channel 3. After all appropriate QA, the patient treatment was started with Channel 1 being the first set of dwell positions treated. At the completion of the Channel 1 treatment, the HDR unit gave an error stating that there was a 'Possible incomplete source retraction in Channel 2.' Even though all radiation indicators did not detect the presence of radiation, and even though the licensee was not using Channel 2, immediate emergency procedures were implemented. The emergency stop was activated and the room was entered with a survey meter to verify that there was no elevated radiation present. All indications were that the source was retracted properly and that there was no danger to the patient or the staff.</br>The error displayed on the treatment screen indicated that it was possible that dust was on the optocoupler, thus causing the fault. However, the error could not be cleared by using the reset button. Nucletron was immediately contacted. Nucletron support personnel attempted to walk the licensee through some steps that may have cleared the error, but they were unsuccessful. Therefore, the remaining part of the patient's treatment was aborted. Nucletron scheduled one of their service engineers to respond to the licensee's facility to repair the unit.</br>The authorized user informed the patient that the complete treatment was not delivered due to the machine malfunction and that the authorized user would determine what action to take on the future fractions. The patient and the treatment room were surveyed prior to release. No elevated readings were observed. The patient received 120 cGy (versus the prescribed dose of 600 cGy). The deviation from the written directive was documented in the patient's chart.</br>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.necessarily result in harm to the patient.
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00:00:00, 13 March 2012 +
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22:25:42, 24 September 2017 +
11:22:00, 13 March 2012 +
1.307 d (31.37 hours, 0.187 weeks, 0.043 months) +
04:00:00, 12 March 2012 +
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