ENS 53506: Difference between revisions

v t e ENS Event
04:00 Jul 13, 2018
Title	Medical Event
Event Description	The following information is a synopsis of information received via E-mail: A HDR [high dose rate] brachytherapy incident occurred in Brunswick Georgia, on July 13, 2018. No one, including the patient, was exposed to excessive radiation. SE Georgia Health Systems treated a Gyn [gynecology] patient using the GammaMed Plus HDR unit and a Tandem and Ring applicator set, both supplied by Varian. Upon completion of the treatment, the source wire retracts back into the shielded HDR unit for safe storage. At that time the room was checked with a survey meter and no exposure readings above background were measured. The HDR unit was surveyed to ensure that the source wire had retracted. The exposure reading on the surface demonstrated that the wire had retracted, and the room was safe. Upon scanning the patient's surface, however, a reading of approximately 2.5mR/hr was measured, which was higher than the expected background reading. The applicator was removed from the patient and scanned, the increased exposure reading was in the applicator. The applicator was placed into a large shielded container provided by Varian and immediately placed in safe storage. The patient, the bedding, and all other materials associated with the implant were re-scanned with no readings above background. The patient was removed from the room, deemed safe and released. The time was recorded to be approximately 5 to 6 minutes and will be used for dose estimates. The HDR unit was re-scanned along with the Linac vault. All were deemed clear and safe. The HDR unit was locked and secured. Patient treatments in the Linac continued. The applicator device was then scanned one piece at a time and it was determined that the Ring portion of the Tandem and Ring set was contaminated. It was assumed that the contamination was secure inside the ring which is a rounded hollow metal tube. Exposure readings at the surface of the ring were 96 mR/hr at the surface and approximately 30 mR/hr at 6 inches. SE Georgia Health Systems notified the Georgia Radiation Protection Programs, and Varian Medical Systems of this incident. 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.

ENS 53506 +/-
Where
Se Georgia Health Systems Brunswick, Georgia (NRC Region 1)
License number:	45-309857-01
Organization:	Varian Medical Systems
Reporting

10 CFR 30.50(b)(2), Licensed Material Protection Equipment Failure
Time - Person (Reporting Time:+12.35 h0.515 days <br />0.0735 weeks <br />0.0169 months <br />)
Opened:	Katharine Arzate 16:21 Jul 13, 2018
NRC Officer:	Thomas Kendzia
Last Updated:	Jul 13, 2018
53506 - NRC Website
v • d • e

v t e Emergency Notification System
Se Georgia Health Systems with 10 CFR 30.50(b)(2), 10 CFR 30.50(b)(3)
WEEKMONTHYEAR2018-07-13T04:00:00 [Table view]
[ENS list for Se Georgia Health Systems]

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 SE Georgia Health Systems notified the Georgia Radiation Protection Programs, and Varian Medical Systems of this incident.
 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.
-| URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2018/20180723en.html#en53506
+| URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2018/20180724en.html#en53506
 }}
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ENS 53506: Difference between revisions

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