ENS 54899: Difference between revisions

v t e ENS Event
05:00 Sep 1, 2020
Title	Agreement State Report - Underdose During Medical Treatment
Event Description	The following information was received via e-mail from the Texas Department of State Health Services (the Agency): On September 14, 2020, the Agency was notified by the licensee's radiation safety officer (RSO) that they had discovered a medical event [occurred September 1, 2020] involving a Varian high dose rate remote afterloader (HDR) unit had occurred. The RSO reported that a patient was to receive two boost treatments using the HDR unit. While setting up for the second treatment, the licensee noted the length of source catheter tube used in the first treatment was incorrect, therefore only part of the intended target was treated. The RSO stated the patient and physician were both notified of the event and that the current plan is to perform an additional treatment to the area that was under exposed in the first treatment. The RSO stated they did not expect any adverse effects to the patient. The Agency has requested additional information on the event. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 9796 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 54899 +/-
Where
Memorial Hermann Health System Houston, Texas (NRC Region 4)
License number:	L06439
Organization:	Texas Dept Of State Health Services
Reporting

Agreement State
Time - Person (Reporting Time:+343.13 h14.297 days <br />2.042 weeks <br />0.47 months <br />)
Opened:	Art Tucker 12:08 Sep 15, 2020
NRC Officer:	Brian P. Smith
Last Updated:	Sep 15, 2020
54899 - NRC Website
v • d • e

v t e Emergency Notification System
Texas Department of State Health Services with Agreement State
WEEKMONTHYEAR	Agreement State Report - Lost and Recovered Camera	Agreement State Report - Gauge Damaged When Struck by Vehicle	Agreement State Report - Underdose During Medical Treatment	Agreement State Report- Shutter Stuck in Open Position	2020-09-08T05:00:00 [Table view]
[ENS list for Texas Department of State Health Services]

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 Texas Incident Number: 9796
 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/2020/20200923en.html#en54899
+| URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2020/20200924en.html#en54899
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Revision as of 06:30, 24 September 2020