ENS 44397: Difference between revisions
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| event date = 08/07/2008 14:00 EDT | | event date = 08/07/2008 14:00 EDT | ||
| last update date = 08/08/2008 | | last update date = 08/08/2008 | ||
| title = Agreement State Report - Underexposure During Hdr Medical Treatment Due | | title = Agreement State Report - Underexposure During Hdr Medical Treatment Due to Equipment Malfunction | ||
| event text = The State received notification of a possible medical event due to an equipment malfunction. The licensee was treating a patient for rectal cancer using an HDR Nucleotron Micro Select Model 105.999 Serial 31776. The prescribed treatment consisted of the administration of 29 catheter doses of Iridium-192. During the 12th catheter dose, an equipment malfunction caused a failure of the administered treatment. The failure mode was Code 200 - "No radiation detected." The failure mode caused the unit to stop treatment by not proceeding to the next catheter. Nucleotron immediately contacted. A service technician is expected to arrive on 8/8/08 for repair of the device. Once the HDR unit is repaired, the treatment plan and written directive will be modified and treatment of the patient resumed. Patient and physician have been advised of the treatment interruption and no adverse impact is expected. | | event text = The State received notification of a possible medical event due to an equipment malfunction. The licensee was treating a patient for rectal cancer using an HDR Nucleotron Micro Select Model 105.999 Serial 31776. The prescribed treatment consisted of the administration of 29 catheter doses of Iridium-192. During the 12th catheter dose, an equipment malfunction caused a failure of the administered treatment. The failure mode was Code 200 - "No radiation detected." The failure mode caused the unit to stop treatment by not proceeding to the next catheter. Nucleotron immediately contacted. A service technician is expected to arrive on 8/8/08 for repair of the device. Once the HDR unit is repaired, the treatment plan and written directive will be modified and treatment of the patient resumed. Patient and physician have been advised of the treatment interruption and no adverse impact is expected. | ||
The State of Ohio plans to send an inspector to the facility on 8/11/08. | The State of Ohio plans to send an inspector to the facility on 8/11/08. | ||
Latest revision as of 22:13, 1 March 2018
| Where | |
|---|---|
| Cleveland Clinic Foundation Cleveland, Ohio (NRC Region 3) | |
| License number: | 02110-18-0013 |
| Organization: | Ohio Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+17.48 h0.728 days <br />0.104 weeks <br />0.0239 months <br />) | |
| Opened: | Mark Light 11:29 Aug 8, 2008 |
| NRC Officer: | Bill Huffman |
| Last Updated: | Aug 8, 2008 |
| 44397 - NRC Website | |