ENS Event | |
|---|---|
06:00 Nov 20, 2023 | |
| Title | Equipment Failure |
| Event Description | The following information was provided by the Texas Department of State Health Services (the Department) via email:
On November 21, 2023, the licensee's radiation safety officer notified the Department that on November 20, 2023, during an intravascular brachytherapy (IVB) procedure, the strontium-90 source train did not reach the dwell position within 15 seconds. When they attempted to retract the source, it would not retract into the fully shielded position in the device, but it was outside the patient. Following established procedures, the delivery system (catheter, source train, etc.) was removed from the patient and placed in the device's emergency box. There were no overexposures to the patient or staff. The licensee used a second device and completed the IVB procedure on the patient. After a short time, the licensee was able to return the source train to the fully shielded position in the device. The manufacturer's representative will be coming onsite to perform an evaluation. The licensee did observe what appeared to be a possible kink in the catheter. More information will be provided as it is obtained in accordance with SA-300. Device Information: Best Vascular Novoste IVB model A1000 Source Information: Source train of 16 strontium-90 sources, current total activity 35.9 millicuries. Texas Incident Number: 10067 Texas NMED Number: TX230053 |
| Where | |
|---|---|
| The Methodist Hospital Houston, Texas (NRC Region 4) | |
| License number: | L00457 |
| Organization: | Texas Dept Of State Health Services |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+31.67 h1.32 days <br />0.189 weeks <br />0.0434 months <br />) | |
| Opened: | Karen Blanchard 13:40 Nov 21, 2023 |
| NRC Officer: | Karen Cotton-Gross |
| Last Updated: | Nov 21, 2023 |
| 56867 - NRC Website | |
The Methodist Hospital with Agreement State | |
WEEKMONTHYEARENS 568672023-11-20T06:00:00020 November 2023 06:00:00
[Table view]Agreement State Equipment Failure ENS 552222021-04-28T06:00:00028 April 2021 06:00:00 Agreement State Medical Event ENS 550332020-12-11T06:00:00011 December 2020 06:00:00 Agreement State Unretractable Source ENS 490892013-06-03T05:00:0003 June 2013 05:00:00 Agreement State Agreement State Report - Source Retraction Failure ENS 486402012-12-04T06:00:0004 December 2012 06:00:00 Agreement State Therapy Source Jammed at the Device Entry Port ENS 479522012-04-10T05:00:00010 April 2012 05:00:00 Agreement State Agreement State Report - Stuck Source in Catheter ENS 457082008-12-10T06:00:00010 December 2008 06:00:00 Agreement State Agreement State Report - Source Stuck in Catheter Tube ENS 409672004-07-28T05:00:00028 July 2004 05:00:00 Agreement State Source Train Did Not Retract ENS 404302004-01-05T14:16:0005 January 2004 14:16:00 Agreement State Agreement State Report: Novoste Strontium-90 Intravasular Brachytherapy (Ivb) Source Discovered Missing. 2023-11-20T06:00:00 | |