ENS 46867: Difference between revisions
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| event date = 05/13/2011 CDT | | event date = 05/13/2011 CDT | ||
| last update date = 05/24/2011 | | last update date = 05/24/2011 | ||
| title = Agreement State Report - Early Termination | | title = Agreement State Report - Early Termination of Radiation Therapy Because of Power Supply Voltage Variation | ||
| event text = On Wednesday May 18th, the licensee's radiation safety officer contacted the agency [Illinois Emergency Management Agency] to advise that a medical event had likely occurred the prior Friday. Based on their initial evaluation, 1 of the 10 fractions prescribed for a patient was not delivered as intended such that less than 50% of the expected dose was delivered during a fraction. | | event text = On Wednesday May 18th, the licensee's radiation safety officer contacted the agency [Illinois Emergency Management Agency] to advise that a medical event had likely occurred the prior Friday. Based on their initial evaluation, 1 of the 10 fractions prescribed for a patient was not delivered as intended such that less than 50% of the expected dose was delivered during a fraction. | ||
The written directive indicates that the patient was scheduled to undergo 10 treatments to her breast twice a day over a period of 5 days. Each treatment involved 340 centiGy for a total written directive prescription of 3,400 centiGy. During the 6th fraction after completion of treatments in channels 1 and 2, the unit experienced a power supply error. Sensing the power variation, the device automatically withdrew the source and did not complete the treatment for channel 3. Although additional attempts were made to clear the error and continue the treatment, none of the remaining 4 channels could be finished. The licensee had experienced similar problems with the device the previous week which had resulted in a service call on May 10. At that time the power supply was adjusted to ensure operation within specifications. The unit operated normally following the repair until the event on the 13th. The power supply as well as main controller board was subsequently replaced by the manufacturer Saturday morning and the patient returned that afternoon to complete the remaining portion of the 6th fraction. All the remaining fractions were delivered without incident. The fraction which finished the overall treatment was completed Tuesday. There have been no errors or incidents noted since the replacement of the above components. | The written directive indicates that the patient was scheduled to undergo 10 treatments to her breast twice a day over a period of 5 days. Each treatment involved 340 centiGy for a total written directive prescription of 3,400 centiGy. During the 6th fraction after completion of treatments in channels 1 and 2, the unit experienced a power supply error. Sensing the power variation, the device automatically withdrew the source and did not complete the treatment for channel 3. Although additional attempts were made to clear the error and continue the treatment, none of the remaining 4 channels could be finished. The licensee had experienced similar problems with the device the previous week which had resulted in a service call on May 10. At that time the power supply was adjusted to ensure operation within specifications. The unit operated normally following the repair until the event on the 13th. The power supply as well as main controller board was subsequently replaced by the manufacturer Saturday morning and the patient returned that afternoon to complete the remaining portion of the 6th fraction. All the remaining fractions were delivered without incident. The fraction which finished the overall treatment was completed Tuesday. There have been no errors or incidents noted since the replacement of the above components. | ||
Revision as of 22:07, 1 March 2018
| Where | |
|---|---|
| Christ Hospital And Medical Center Oak Lawn, Illinois (NRC Region 3) | |
| License number: | Il-01720-01 |
| Organization: | Illinois Emergency Mgmt. Agency |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+179.6 h7.483 days <br />1.069 weeks <br />0.246 months <br />) | |
| Opened: | Daren Perrero 16:36 May 20, 2011 |
| NRC Officer: | Mark Abramovitz |
| Last Updated: | May 24, 2011 |
| 46867 - NRC Website | |