ENS 54511
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ENS Event | |
|---|---|
06:00 Feb 4, 2020 | |
| Title | Agreement State Report - Brachytherapy Source Failed to Retract |
| Event Description | The following information was received from the state of Texas via email:
The Methodist Hospital reported a source retraction failure during an intravascular Brachytherapy treatment performed on 2/4/2020. The intravascular brachytherapy system (Best Vascular Model A-1000 Serial #89670) contained a 1.3 GBq (35.2 mCi) Sr-90 source (AEA Model SICW.2 Serial #ZA925). The patient was treated as prescribed and the source was completely out of the patient. As it was retracting into the device, it didn't go into home position. The device was immediately placed in the emergency equipment box (shielding box) per manufacturer's instructions for response to this type of occurrence. There was no underexposure or overexposure to the patient. The manufacturer has been contacted to investigate and conduct repairs. Additional information in accordance with SA-300 will be provided. Texas Incident No.: 9739 |
| Where | |
|---|---|
| Texas Dept Of State Health Services Houston, Texas (NRC Region 4) | |
| License number: | L00457 |
| Organization: | Texas Dept Of State Health Services |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+27.52 h1.147 days <br />0.164 weeks <br />0.0377 months <br />) | |
| Opened: | Chris Moore 09:31 Feb 5, 2020 |
| NRC Officer: | Howie Crouch |
| Last Updated: | Feb 5, 2020 |
| 54511 - NRC Website | |
Texas Department of State Health Services with Agreement State | |||||||
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