ENS 45708: Difference between revisions
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| event date = 12/10/2008 CST | | event date = 12/10/2008 CST | ||
| last update date = 02/18/2010 | | last update date = 02/18/2010 | ||
| title = Agreement State Report - Source Stuck | | title = Agreement State Report - Source Stuck in Catheter Tube | ||
| event text = The following information was obtained from NMED: | | event text = The following information was obtained from NMED: | ||
The Methodist Hospital reported that a 1.91 GBq (51.57 mCi) Sr-90 source (BEBIG model Sr0.S03, serial #ZB523) became stuck in a catheter during a patient's treatment on 12/10/2008, using a Novoste Beta-Cath system (model A1732, serial 91277). The catheter was removed from the patient and placed into a bailout box. The bailout box was returned to storage and additional shielding was used to ensure dose rates in the area were ALARA. There was no additional exposure to any individual involved. A preliminary visual inspection of the device indicated that there may be a small kink in the capillary tube, which prevented the source from returning to its secured location. The source was returned to the manufacturer for further investigation. The manufacturer determined that the source became stuck due to kinks in the delivery catheter. They provided additional guidance to the hospital in the use of the system to help minimize recurrence. | The Methodist Hospital reported that a 1.91 GBq (51.57 mCi) Sr-90 source (BEBIG model Sr0.S03, serial #ZB523) became stuck in a catheter during a patient's treatment on 12/10/2008, using a Novoste Beta-Cath system (model A1732, serial 91277). The catheter was removed from the patient and placed into a bailout box. The bailout box was returned to storage and additional shielding was used to ensure dose rates in the area were ALARA. There was no additional exposure to any individual involved. A preliminary visual inspection of the device indicated that there may be a small kink in the capillary tube, which prevented the source from returning to its secured location. The source was returned to the manufacturer for further investigation. The manufacturer determined that the source became stuck due to kinks in the delivery catheter. They provided additional guidance to the hospital in the use of the system to help minimize recurrence. |
Latest revision as of 22:10, 1 March 2018
Where | |
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The Methodist Hospital Houston, Texas (NRC Region 4) | |
License number: | L-00457 |
Organization: | Texas Department Of Health |
Reporting | |
Agreement State | |
Time - Person (Reporting Time:+10444.97 h435.207 days <br />62.172 weeks <br />14.308 months <br />) | |
Opened: | Art Tucker 10:58 Feb 18, 2010 |
NRC Officer: | Howie Crouch |
Last Updated: | Feb 18, 2010 |
45708 - NRC Website | |