ENS 41720: Difference between revisions

From kanterella

Latest revision as of 22:20, 1 March 2018

v t e ENS Event
19:30 Apr 17, 2005
Title	Part 21 Report - Malfunction of Novoste Intravascular Brachytherapy Beta-Cath System Transfer Device
Event Description	During a medical procedure on a patient, two individual coronary artery locations were being irradiated with Sr-90 (2.05 GBq, serial # ZA-494. The device being used, Novoste Intravascular Brachytherapy Beta-Cath System Transfer (S/N# 90556], hereinafter called "Device", failed to work properly. The licensee noticed the source did not retract into the Device. At this point the licensee pulled the entire catheter out of the patient, and within one minute was able to return the sources safely into the Device. It was assumed the problem was with the catheter and it's connection to the Device. The licensee continued to the next location on the patient. Upon attempting to return the source, the licensee noticed the sources were not moving from the patient. Within 5-10 seconds, the licensee pulled the entire catheter from the patient, and then placed the entire system into the "bailout" box for proper shielding from beta radiation. The next day the licensee called Novoste and explained the events. Novoste determined it was a faulty Device and sent the licensee a replacement. On May 19, 2005 the replacement arrived and the faulty device was sent back to the company.

ENS 41720 +/-
Where
Bryn Mawr Hospital Bryn Mawr, Pennsylvania (NRC Region 1)
License number:	37-07722-04
Organization:	Bryn Mawr Hospital
Reporting

10 CFR 21.21
Time - Person (Reporting Time:+764.45 h31.852 days <br />4.55 weeks <br />1.047 months <br />)
Opened:	Michael Bieda 15:57 May 19, 2005
NRC Officer:	John Knoke
Last Updated:	May 19, 2005
41720 - NRC Website
v • d • e

v t e Emergency Notification System
Bryn Mawr Hospital with 10 CFR 21.21, Notification of failure to comply or existence of a defect and its evaluation
WEEKMONTHYEAR2005-04-17T19:30:00 [Table view]
[ENS list for Bryn Mawr Hospital]

@@ Line 16: / Line 16: @@
 | event date = 04/17/2005 15:30 EDT
 | last update date = 05/19/2005
-| title = Part 21 Report - Malfunction Of Novoste Intravascular Brachytherapy Beta-Cath System Transfer Device
+| title = Part 21 Report - Malfunction of Novoste Intravascular Brachytherapy Beta-Cath System Transfer Device
 | event text = During a medical procedure on a patient, two individual coronary artery locations were being irradiated with Sr-90 (2.05 GBq, serial #  ZA-494.  The device being used, Novoste Intravascular Brachytherapy Beta-Cath System Transfer (S/N# 90556], hereinafter called "Device", failed to work properly.
 The licensee noticed the source did not retract into the Device.  At this point the licensee pulled the entire catheter out of the patient, and within one minute was able to return the sources safely into the Device. It was assumed the problem was with the catheter and it's connection to the Device.