ENS 54585
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ENS Event | |
|---|---|
05:00 Mar 13, 2020 | |
| Title | Agreement State Report - Patient Underdose |
| Event Description | 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 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />. An investigation into this event is ongoing. More information will be provided when obtained in accordance with SA-300. Texas Incident Number: 9751 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 | |
|---|---|
| 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 | |
Texas Department of State Health Services with Agreement State | |||||||
ENS 548912020-09-08T05:00:0008 September 2020 05:00:00 Agreement State | Agreement State Report - Lost and Recovered Camera ENS 548862020-09-05T05:00:0005 September 2020 05:00:00 Agreement State | Agreement State Report - Gauge Damaged When Struck by Vehicle ENS 548992020-09-01T05:00:0001 September 2020 05:00:00 Agreement State | Agreement State Report - Underdose During Medical Treatment ENS 548722020-08-31T05:00:00031 August 2020 05:00:00 Agreement State | Agreement State Report- Shutter Stuck in Open Position ENS 548662020-08-29T14:00:00029 August 2020 14:00:00 Agreement State Agreement State Report - Stolen Vehicle with Moisture Density Gauge ENS 548652020-08-28T05:00:00028 August 2020 05:00:00 Agreement State ENS 548622020-08-26T05:00:00026 August 2020 05:00:00 Agreement State ENS 548572020-08-24T05:00:00024 August 2020 05:00:00 Agreement State Agreement State Report - Nuclear Gauge Shutter Stuck Open ENS 548512020-08-21T13:00:00021 August 2020 13:00:00 Agreement State | ENS 548372020-08-13T05:00:00013 August 2020 05:00:00 Agreement State ENS 548152020-08-03T05:00:0003 August 2020 05:00:00 Agreement State Agreement State Report - Patient Underdose ENS 548102020-08-01T17:00:0001 August 2020 17:00:00 Agreement State Agreement State Report - Lost Moisture Density Gauge ENS 548052020-07-29T05:00:00029 July 2020 05:00:00 Agreement State Agreement State Report - Stuck Shutters ENS 547552020-06-23T14:00:00023 June 2020 14:00:00 Agreement State Agreement State Report - High Dose Rate Tandem Applicator Broken During Treatment ENS 547442020-06-09T05:00:0009 June 2020 05:00:00 Agreement State Agreement State Report - Stuck Shutter ENS 547302020-05-29T04:00:00029 May 2020 04:00:00 Agreement State Agreement State Report - Loss of Control of Radioactive Material ENS 547232020-05-21T05:00:00021 May 2020 05:00:00 Agreement State Agreement State Report - Stolen Moisture Density Gauge ENS 547062020-05-10T05:00:00010 May 2020 05:00:00 Agreement State ENS 546982020-05-07T05:00:0007 May 2020 05:00:00 Agreement State Agreement State Report - Damaged Nuclear Gauge ENS 546672020-04-09T05:00:0009 April 2020 05:00:00 Agreement State Agreement State Report - Dose Not Delivered to the Correct Location During Brachytherapy Treatment ENS 546232020-03-27T05:00:00027 March 2020 05:00:00 Agreement State Agreement State Report - Underdose of Patient Medical Event ENS 545862020-03-16T05:00:00016 March 2020 05:00:00 Agreement State Agreement State Report - Radiography Source Guide Tube Damaged ENS 545852020-03-13T05:00:00013 March 2020 05:00:00 Agreement State Agreement State Report - Patient Underdose ENS 545792020-03-10T05:00:00010 March 2020 05:00:00 Agreement State Agreement State Report - Stuck Open Shutter ENS 545532020-03-01T06:00:0001 March 2020 06:00:00 Agreement State Agreement State Report - Loss of Control of Radioactive Material ENS 545402020-02-24T06:00:00024 February 2020 06:00:00 Agreement State Agreement State Report - Stolen Density Gauge ENS 546262020-02-24T05:00:00024 February 2020 05:00:00 Agreement State Agreement State Report - Lost Static Control Device ENS 545342020-02-19T06:00:00019 February 2020 06:00:00 Agreement State Agreement State Report - Underdose of Yttrium-90 During Treatment ENS 545212020-02-11T06:00:00011 February 2020 06:00:00 Agreement State Agreement State Report - Qsa Exposure Device Open Shutter and Cap ENS 545112020-02-04T06:00:0004 February 2020 06:00:00 Agreement State Agreement State Report - Brachytherapy Source Failed to Retract ENS 544992020-01-29T06:00:00029 January 2020 06:00:00 Agreement State Texas Agreement State Report - Contamination Event Resulting in Restricted Access ENS 544862020-01-21T06:00:00021 January 2020 06:00:00 Agreement State Texas Agreement State Report - Stolen Moisture Density Gauge ENS 544822020-01-15T06:00:00015 January 2020 06:00:00 Agreement State Agreement State Report - Radiography Camera Source Disconnect ENS 544752020-01-12T06:00:00012 January 2020 06:00:00 Agreement State Agreement State - Fixed Gauge Stuck Shutter ENS 544562019-12-20T06:00:00020 December 2019 06:00:00 Agreement State Agreement State Report - Three Gauge Shutters Inoperable ENS 530082017-10-10T16:35:00010 October 2017 16:35:00 Agreement State Alarm System Breach 2020-09-08T05:00:00 [Table view] | ||
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