ENS 54585: Difference between revisions
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{{ENS notification | {{ENS notification | ||
| event number = 54585 | | event number = 54585 | ||
| facility = | | facility = | ||
| Organization = Texas Dept Of State Health Services | | Organization = Texas Dept Of State Health Services | ||
| license number = RAM-L00457 | | license number = RAM-L00457 | ||
| Line 10: | Line 10: | ||
| utype = | | utype = | ||
| cfr = Agreement State | | cfr = Agreement State | ||
| emergency class = | | emergency class = Non Emergency | ||
| notification date = 03/13/2020 19:28 | | notification date = 03/13/2020 19:28 | ||
| notification by = Randall Redd | | notification by = Randall Redd | ||
| Line 19: | Line 19: | ||
| event text = The following was received from the State of Texas via email: | | event text = The following was received from the State of Texas via email: | ||
On March 13, 2020, [the Texas Department of State Health Services] was notified by the Houston Methodist Hospital of a medical event. The patient was to receive 18.4 Gy of therapeutic dose from a Novoste Beta-Cath system Sr-90 source (system serial no. 89670, source train serial no. za925). When the procedure began, the command was sent to the system to deliver the source. The source did not appear within the fluoro field as expected after 10 seconds and the command was sent to the system to retract the source. The source failed to retract. The oncologist manually removed the catheter from the patient and found the source stuck inside. It is now back in the system. The licensee has been reminded that they need to notify the referring physician within 24 hours. An investigation into this event is ongoing. More information will be provided when obtained in accordance with SA-300. | On March 13, 2020, [the Texas Department of State Health Services] was notified by the Houston Methodist Hospital of a medical event. The patient was to receive 18.4 Gy of therapeutic dose from a Novoste Beta-Cath system Sr-90 source (system serial no. 89670, source train serial no. za925). When the procedure began, the command was sent to the system to deliver the source. The source did not appear within the fluoro field as expected after 10 seconds and the command was sent to the system to retract the source. The source failed to retract. The oncologist manually removed the catheter from the patient and found the source stuck inside. It is now back in the system. The licensee has been reminded that they need to notify the referring physician within 24 hours. An investigation into this event is ongoing. More information will be provided when obtained in accordance with SA-300. | ||
Texas Incident Number: | Texas Incident Number: 9751 | ||
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/2020/20200324en.html#en54585 | | URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2020/20200324en.html#en54585 | ||
}} | }} | ||
{{ENS-Nav}} | {{ENS-Nav}} | ||
Latest revision as of 12:48, 15 January 2021
| Where | |
|---|---|
| Texas Dept Of State Health Services Houston, Texas (NRC Region 4) | |
| License number: | RAM-L00457 |
| Organization: | Texas Dept Of State Health Services |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+14.47 h0.603 days <br />0.0861 weeks <br />0.0198 months <br />) | |
| Opened: | Randall Redd 19:28 Mar 13, 2020 |
| NRC Officer: | Jeffrey Whited |
| Last Updated: | Mar 13, 2020 |
| 54585 - NRC Website | |