ENS Event | |
|---|---|
06:00 Dec 10, 2008 | |
| Title | Agreement State Report - Source Stuck in Catheter Tube |
| Event Description | The following information was obtained from NMED:
The Methodist Hospital reported that a 1.91 GBq (51.57 mCi) Sr-90 source (BEBIG model Sr0.S03, serial #ZB523) became stuck in a catheter during a patient's treatment on 12/10/2008, using a Novoste Beta-Cath system (model A1732, serial 91277). The catheter was removed from the patient and placed into a bailout box. The bailout box was returned to storage and additional shielding was used to ensure dose rates in the area were ALARA. There was no additional exposure to any individual involved. A preliminary visual inspection of the device indicated that there may be a small kink in the capillary tube, which prevented the source from returning to its secured location. The source was returned to the manufacturer for further investigation. The manufacturer determined that the source became stuck due to kinks in the delivery catheter. They provided additional guidance to the hospital in the use of the system to help minimize recurrence. The State of Texas discovered that the event was reported to NMED but not to the NRC Headquarters Operations Center as required therefore they are making a late report. Texas Report Number: I-8590 |
| Where | |
|---|---|
| The Methodist Hospital Houston, Texas (NRC Region 4) | |
| License number: | L-00457 |
| Organization: | Texas Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+10444.97 h435.207 days <br />62.172 weeks <br />14.308 months <br />) | |
| Opened: | Art Tucker 10:58 Feb 18, 2010 |
| NRC Officer: | Howie Crouch |
| Last Updated: | Feb 18, 2010 |
| 45708 - 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 | |