Event Notification Report for February 04, 2020
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/03/2020 - 02/04/2020
EVENT NUMBERS
54511
Agreement State
Event Number: 54511
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: THE METHODIST HOSPITAL
Region: 4
City: HOUSTON State: TX
County:
License #: L00457
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: HOWIE CROUCH
Licensee: THE METHODIST HOSPITAL
Region: 4
City: HOUSTON State: TX
County:
License #: L00457
Agreement: Y
Docket:
NRC Notified By: CHRIS MOORE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 02/05/2020
Notification Time: 09:31 [ET]
Event Date: 02/04/2020
Event Time: 00:00 [CST]
Last Update Date: 02/05/2020
Notification Time: 09:31 [ET]
Event Date: 02/04/2020
Event Time: 00:00 [CST]
Last Update Date: 02/05/2020
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
NICK TAYLOR (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - BRACHYTHERAPY SOURCE FAILED TO RETRACT
The following information was received from the state of Texas via email:
"The Methodist Hospital reported a source retraction failure during an intravascular Brachytherapy treatment performed on 2/4/2020. The intravascular brachytherapy system (Best Vascular Model A-1000 Serial #89670) contained a 1.3 GBq (35.2 mCi) Sr-90 source (AEA Model SICW.2 Serial #ZA925). The patient was treated as prescribed and the source was completely out of the patient. As it was retracting into the device, it didn't go into home position. The device was immediately placed in the emergency equipment box (shielding box) per manufacturer's instructions for response to this type of occurrence. There was no underexposure or overexposure to the patient. The manufacturer has been contacted to investigate and conduct repairs. Additional information in accordance with SA-300 will be provided."
Texas Incident No.: 9739
The following information was received from the state of Texas via email:
"The Methodist Hospital reported a source retraction failure during an intravascular Brachytherapy treatment performed on 2/4/2020. The intravascular brachytherapy system (Best Vascular Model A-1000 Serial #89670) contained a 1.3 GBq (35.2 mCi) Sr-90 source (AEA Model SICW.2 Serial #ZA925). The patient was treated as prescribed and the source was completely out of the patient. As it was retracting into the device, it didn't go into home position. The device was immediately placed in the emergency equipment box (shielding box) per manufacturer's instructions for response to this type of occurrence. There was no underexposure or overexposure to the patient. The manufacturer has been contacted to investigate and conduct repairs. Additional information in accordance with SA-300 will be provided."
Texas Incident No.: 9739