ENS Event | |
|---|---|
04:00 Feb 21, 2019 | |
| Title | Agreement State Report - Equipment Failure During Medical Treatment |
| Event Description | The following report was received from the Pennsylvania Bureau of Radiation Protection (PA DEP) via facsimile:
As a result of a Departmental [PA DEP] inspection the licensee reported an equipment failure event that occurred on February 21, 2019. The equipment was a Varian GammaMed Plus, Serial #641017, containing 6.518 Ci of lr-192. A patient was receiving her last of three fractions of treatment with total treatment time for this fraction being 222.6 seconds divided through a total of eight positions. Twenty-five seconds into treatment the unit issued an inactive source error and retracted the source. The physicist entered the room to confirm that the source was retracted. The manufacturer was called. At the manufacturer's recommendation, the console key was powered off, then back on, and the remaining treatment was initiated to continue with the untreated area. This time at 25.8 seconds into the treatment the same error occurred. The remaining treatment plan was saved into the planning computer, and the patient had the applicator removed and was sent home. Varian sent a field service representative who successfully replaced the Geiger-Muller board and functionality was verified. The patient was then rescheduled. The continued treatment on February 25, 2019 accurately reflected the partial treatment and was appropriately scaled to reflect the source decay from the previous treatment. The final portion of the treatment was delivered without incident. There was no harm or overexposure to the patient. The patient was informed at the time. The attending physician has not been notified. Event Report ID No.: PA190018 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. |
| Where | |
|---|---|
| Robert Packer Hospital Sayre, Pa Sayre, Pennsylvania (NRC Region 1) | |
| License number: | PA-0012 |
| Organization: | Pa Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+4139.08 h172.462 days <br />24.637 weeks <br />5.67 months <br />) | |
| Opened: | John Chippo 14:05 Aug 12, 2019 |
| NRC Officer: | Thomas Kendzia |
| Last Updated: | Aug 12, 2019 |
| 54213 - NRC Website | |
Robert Packer Hospital Sayre, Pa with Agreement State | |
WEEKMONTHYEARENS 542132019-02-21T04:00:00021 February 2019 04:00:00
[Table view]Agreement State Agreement State Report - Equipment Failure During Medical Treatment 2019-02-21T04:00:00 | |