ENS Event | |
|---|---|
05:00 Jul 28, 2004 | |
| Title | Source Train Did Not Retract |
| Event Description | After IVB therapy the source train did not retract due to a kink in the IVB catheter, did not retract to the remote Beta-Cath device. The IVB catheter was immediately withdrawn and placed in the Novoste emergency plexiglass storage safe and then in the IVB storage room. No overexposure was received by the patient or attending staff. Novoste has been notified of the malfunction. The Novoste Beta Cath was returned to the manufacture on August 2, 2004. The IVB manufacturer is Novoste Beth Cath, source Sr-90, 1.71 GBq (46 millicuries). Transfer device Serial No. 92917, and Source train Serial No. ZA543. The device was packaged and returned to the manufacturer on August 2, 2004. This agency did not receive notice of the event within 24-hours
Texas Incident No.: I-8155 |
| Where | |
|---|---|
| The Methodist Hospital Houston, Texas (NRC Region 4) | |
| License number: | L00457 |
| Organization: | Texas Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+514.35 h21.431 days <br />3.062 weeks <br />0.705 months <br />) | |
| Opened: | James Ogden 15:21 Aug 18, 2004 |
| NRC Officer: | Chauncey Gould |
| Last Updated: | Aug 18, 2004 |
| 40967 - 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 | |