Event Notification Report for February 21, 2018
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/20/2018 - 02/21/2018
EVENT NUMBERS
53226
Agreement State
Event Number: 53226
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: TEXAS ONCOLOGY PA
Region: 4
City: AUSTIN State: TX
County:
License #: 06090
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: STEVEN VITTO
Licensee: TEXAS ONCOLOGY PA
Region: 4
City: AUSTIN State: TX
County:
License #: 06090
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: STEVEN VITTO
Notification Date: 02/22/2018
Notification Time: 18:51 [ET]
Event Date: 02/21/2018
Event Time: 00:00 [CST]
Last Update Date: 02/22/2018
Notification Time: 18:51 [ET]
Event Date: 02/21/2018
Event Time: 00:00 [CST]
Last Update Date: 02/22/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
GREG PICK (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - MEDICAL EVENT
The following was received via email from the State of Texas:
"On February 22, 2018, the licensee notified the Agency [Texas Department of State Health Services] that it had made the determination a medical event had occurred. On February 19, 2018, a patient received first fraction of treatment plan delivered by high dose rate afterloader (HDR) utilizing iridium-192. The patient returned on February 21st for the second fraction. The physicist was reviewing the information prior to treatment and found an error had occurred with the first treatment.
"The licensee investigated and conducted dose reconstruction. The licensee's investigation revealed that the physicist performing the digitization of the 13 channels on HDR applicator had digitized channel #12 and when he went to channel #13 he failed to 'tell' the machine, which added the 5.5 centimeters that should have been in channel #13 onto channel #12. There was a high dwell time at the end of the extended 5.5 centimeters which resulted in a dose to tissue outside the target volume that exceeds 50 rem and 50% or more of the dose expected. The licensee reported a small amount of tissue received, and should tolerate, the extra dose. The referring physician has been notified. More information will be provided as it is obtained and in accordance with SA-300."
Texas Incident #: I -9546
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.
The following was received via email from the State of Texas:
"On February 22, 2018, the licensee notified the Agency [Texas Department of State Health Services] that it had made the determination a medical event had occurred. On February 19, 2018, a patient received first fraction of treatment plan delivered by high dose rate afterloader (HDR) utilizing iridium-192. The patient returned on February 21st for the second fraction. The physicist was reviewing the information prior to treatment and found an error had occurred with the first treatment.
"The licensee investigated and conducted dose reconstruction. The licensee's investigation revealed that the physicist performing the digitization of the 13 channels on HDR applicator had digitized channel #12 and when he went to channel #13 he failed to 'tell' the machine, which added the 5.5 centimeters that should have been in channel #13 onto channel #12. There was a high dwell time at the end of the extended 5.5 centimeters which resulted in a dose to tissue outside the target volume that exceeds 50 rem and 50% or more of the dose expected. The licensee reported a small amount of tissue received, and should tolerate, the extra dose. The referring physician has been notified. More information will be provided as it is obtained and in accordance with SA-300."
Texas Incident #: I -9546
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.