ENS 54899: Difference between revisions
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{{ENS notification | {{ENS notification | ||
| event number = 54899 | | event number = 54899 | ||
| facility = | | facility = | ||
| Organization = Texas Dept Of State Health Services | | Organization = Texas Dept Of State Health Services | ||
| license number = L06439 | | license number = L06439 | ||
| Line 10: | Line 10: | ||
| utype = | | utype = | ||
| cfr = Agreement State | | cfr = Agreement State | ||
| emergency class = | | emergency class = Non Emergency | ||
| notification date = 09/15/2020 12:08 | | notification date = 09/15/2020 12:08 | ||
| notification by = Art Tucker | | notification by = Art Tucker | ||
| Line 16: | Line 16: | ||
| event date = 09/01/2020 00:00 CDT | | event date = 09/01/2020 00:00 CDT | ||
| last update date = 09/15/2020 | | last update date = 09/15/2020 | ||
| title = Agreement State Report - Underdose During Medical Treatment | | title = <Td Align="Left" Scope="Row">Agreement State Report - Underdose During Medical Treatment | ||
| event text = The following information was received via e-mail from the Texas Department of State Health Services (the Agency): | | event text = 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. | 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 | Texas Incident Number: 9796 | ||
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. | 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/2020/20200924en.html#en54899 | | URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2020/20200924en.html#en54899 | ||
}} | }} | ||
{{ENS-Nav}} | {{ENS-Nav}} | ||
Latest revision as of 11:19, 15 January 2021
| Where | |
|---|---|
| Texas Dept Of State Health Services 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 | |