ENS Event | |
|---|---|
18:00 Aug 7, 2008 | |
| Title | Agreement State Report - Underexposure During Hdr Medical Treatment Due to Equipment Malfunction |
| Event Description | The State received notification of a possible medical event due to an equipment malfunction. The licensee was treating a patient for rectal cancer using an HDR Nucleotron Micro Select Model 105.999 Serial 31776. The prescribed treatment consisted of the administration of 29 catheter doses of Iridium-192. During the 12th catheter dose, an equipment malfunction caused a failure of the administered treatment. The failure mode was Code 200 - "No radiation detected." The failure mode caused the unit to stop treatment by not proceeding to the next catheter. Nucleotron immediately contacted. A service technician is expected to arrive on 8/8/08 for repair of the device. Once the HDR unit is repaired, the treatment plan and written directive will be modified and treatment of the patient resumed. Patient and physician have been advised of the treatment interruption and no adverse impact is expected.
The State of Ohio plans to send an inspector to the facility on 8/11/08. 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 | |
|---|---|
| Cleveland Clinic Foundation Cleveland, Ohio (NRC Region 3) | |
| License number: | 02110-18-0013 |
| Organization: | Ohio Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+17.48 h0.728 days <br />0.104 weeks <br />0.0239 months <br />) | |
| Opened: | Mark Light 11:29 Aug 8, 2008 |
| NRC Officer: | Bill Huffman |
| Last Updated: | Aug 8, 2008 |
| 44397 - NRC Website | |
Cleveland Clinic Foundation with Agreement State | |
WEEKMONTHYEARENS 551572021-03-26T18:00:00026 March 2021 18:00:00
[Table view]Agreement State Medical Event Report - Underdosage ENS 536722018-10-16T04:00:00016 October 2018 04:00:00 Agreement State En Revision Imported Date 7/24/2019 ENS 498152014-01-24T05:00:00024 January 2014 05:00:00 Agreement State Agreement State Report - Medical Event Involving Unintended Dose ENS 470712011-07-12T15:00:00012 July 2011 15:00:00 Agreement State Agreement State Report - Patient Received Treatment to Incorrect Organ ENS 465722010-12-08T05:00:0008 December 2010 05:00:00 Agreement State Agreement State Report - Potential Underdose to Patient Due to Aborted Treatment ENS 463762010-10-29T04:00:00029 October 2010 04:00:00 Agreement State Agreement State - Dose Delivered to Wrong Organ ENS 462862010-09-27T04:00:00027 September 2010 04:00:00 Agreement State Ohio Agreement State Report - 95% Medical Underdosage Due to Equipment Failure ENS 443972008-08-07T18:00:0007 August 2008 18:00:00 Agreement State Agreement State Report - Underexposure During Hdr Medical Treatment Due to Equipment Malfunction ENS 405752004-03-04T21:00:0004 March 2004 21:00:00 Agreement State the Cleveland Clinic Foundation Administered an Underdose During a Therapeutic Treatment 2021-03-26T18:00:00 | |