ENS 43445: Difference between revisions
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StriderTol (talk | contribs) Created page by program invented by Mark Hawes |
StriderTol (talk | contribs) Created page by program invented by StriderTol |
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| event date = 06/25/2007 PDT | | event date = 06/25/2007 PDT | ||
| last update date = 06/26/2007 | | last update date = 06/26/2007 | ||
| title = Oregon Agreement State Report - Underdose Due | | title = Oregon Agreement State Report - Underdose Due to Equipment Malfunction | ||
| event text = On June 25, 2007, during a patient treatment, the computer operating the Varian VariSource High Dose Rate After loader reported an error 18, Wire drift detected. This indicated that the source wire positioning system was out-of-specification and the HDR was terminating treatment. Treatment was immediately discontinued and the patient removed from the room. The positioning QA was performed and the system found to be within typical operating limits. The treatment was resumed, but the same error recurred. Treatment was discontinued with only a partial treatment delivered. No errors in positioning or site occurred. The physician and patient were notified immediately after the treatment was terminated. | | event text = On June 25, 2007, during a patient treatment, the computer operating the Varian VariSource High Dose Rate After loader reported an error 18, Wire drift detected. This indicated that the source wire positioning system was out-of-specification and the HDR was terminating treatment. Treatment was immediately discontinued and the patient removed from the room. The positioning QA was performed and the system found to be within typical operating limits. The treatment was resumed, but the same error recurred. Treatment was discontinued with only a partial treatment delivered. No errors in positioning or site occurred. The physician and patient were notified immediately after the treatment was terminated. | ||
Varian Service was notified of the occurrence and a field engineer was dispatched to clean the system the following day. The source and dummy wire transport systems were cleaned and tested. The medical physicists performed several QA tests concerning positioning and source output, and certified the HDR After loader system as ready for patient treatment. | Varian Service was notified of the occurrence and a field engineer was dispatched to clean the system the following day. The source and dummy wire transport systems were cleaned and tested. The medical physicists performed several QA tests concerning positioning and source output, and certified the HDR After loader system as ready for patient treatment. | ||
Revision as of 21:16, 1 March 2018
| Where | |
|---|---|
| Providence Medford Medical Center Medford, Oregon (NRC Region 4) | |
| License number: | Ore-91035 |
| Organization: | Or Dept Of Health Rad Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+36.2 h1.508 days <br />0.215 weeks <br />0.0496 months <br />) | |
| Opened: | Kevin Siebert 19:12 Jun 26, 2007 |
| NRC Officer: | Jeff Rotton |
| Last Updated: | Jun 26, 2007 |
| 43445 - NRC Website | |