ENS Event | |
|---|---|
05:00 Sep 29, 2004 | |
| Title | Agreement State Report Involving an Intravascular Brachytherapy Event |
| Event Description | The following information was received via facsimile:
NY-06-006 Intravascular Brachytherapy event. (NYS DOH Internal Tracking No 278) New York law prohibits the release of any identities in cases of medical events. Therefore the facility name, etc., is not contained in this report. The RSO from the Hospital called on 9/30/04 to report a Novoste Beta Cath IVBT malfunction on 9/29/04. They were using 3.5 French catheter system. They had some difficulty accomplishing a 90-degree bend; at the end of the 3 min 14 seconds treatment time, their attempts to retract the source train failed and the cardiologist had to pull out the catheter manually along with the source train. They notified the FDA and NOVOSTE. They calculated that the patient's heart received a dose of 20 cGy, which the oncologist stated is within tolerance and he anticipates no adverse consequences for the patient. Since the intended dose was delivered to the treatment site, the oncologist believes this is not a medical event. An estimate of dose to the cardiologist's hand indicates an extremity exposure of no more than 3.85 rem which will be added to his annual exposure record. |
| Where | |
|---|---|
| Not Disclosed By State Law New York (NRC Region 1) | |
| Organization: | New York State Dept. Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+12273.42 h511.393 days <br />73.056 weeks <br />16.812 months <br />) | |
| Opened: | R. Dansereau (Via Fax) 15:25 Feb 22, 2006 |
| NRC Officer: | Steve Sandin |
| Last Updated: | Feb 22, 2006 |
| 42363 - NRC Website | |
Not Disclosed By State Law with Agreement State | |
WEEKMONTHYEARENS 423602005-11-29T05:00:00029 November 2005 05:00:00
[Table view]Agreement State Agreement State Report Involving a Broken I-125 Brachytherapy Seed ENS 423642004-11-05T05:00:0005 November 2004 05:00:00 Agreement State Agreement State Report Involving an I-131 Radiopharmaceutical Misadministration ENS 423632004-09-29T05:00:00029 September 2004 05:00:00 Agreement State Agreement State Report Involving an Intravascular Brachytherapy Event ENS 423622004-05-26T05:00:00026 May 2004 05:00:00 Agreement State Agreement State Report Involving an Intravascular Brachytherapy Event ENS 423592003-12-14T05:00:00014 December 2003 05:00:00 Agreement State Agreement State Report Involving a Medical Misadministration ENS 423582003-04-17T05:00:00017 April 2003 05:00:00 Agreement State Agreement State Report Involving a Radiopharmaceutical Misadministration 2005-11-29T05:00:00 | |