Event Notification Report for May 05, 2020
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/04/2020 - 05/05/2020
EVENT NUMBERS
54696
Agreement State
Event Number: 54696
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: HOLY SPIRIT HOSPITAL
Region: 1
City: MECHANICSBURG State: PA
County:
License #: PA-0249
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: ANDREW WAUGH
Licensee: HOLY SPIRIT HOSPITAL
Region: 1
City: MECHANICSBURG State: PA
County:
License #: PA-0249
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: ANDREW WAUGH
Notification Date: 05/06/2020
Notification Time: 12:43 [ET]
Event Date: 05/05/2020
Event Time: 00:00 [EDT]
Last Update Date: 05/12/2020
Notification Time: 12:43 [ET]
Event Date: 05/05/2020
Event Time: 00:00 [EDT]
Last Update Date: 05/12/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
GLENN DENTEL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
GLENN DENTEL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was received via email:
"The Department [Pennsylvania Bureau of Radiation Protection] received notification from a licensee on May 5, 2020, of a medical event involving a Varian GammMedplus iX high dose rate remote afterloader (HDR) containing 8.6 Ci of iridium 192. The patient was set to receive 10 fractions (channels) of breast cancer treatment. An error was noted when treatment from the third channel was attempted. The source was retracted back into the safe position upon the error indication. Staff reset the unit and rebooted. The unit functioned normally for the fourth channel. During the fifth channel the machine experienced another fault, but the source did not automatically retract. Staff then attempted two emergency stop procedures; however, both failed. Staff were finally able to manually retract the source after approximately two to four minutes; however, it hasn't been determined if the source was completely retracted into the shielded safe on the HDR due to catheter interference. The patient was quickly disconnected from the catheter, everyone was immediately removed, and the room was secured from entry. No dose is expected outside the HDR room as it is housed within an accelerator vault. The manufacturer has been contacted. The licensee has also requested the log files from the manufacturer for dose reconstruction of those involved. The department is currently in contact with the licensee and will update this event as soon as more information is provided."
PA Event Report ID No: PA200011
* * * UPDATE ON 5/7/20 AT 1208 EDT FROM JOHN CHIPPO TO ANDREW WAUGH * * *
The following information was received via email:
"Manufacturer service technicians removed the wire/source from the afterloader on 5/6/2020. Preliminarily, it appears the source became stuck approximately 4 to 5 inches from the shielded park position (inside the afterloader, but outside the shielded safe). Dosimetry badges have been sent for emergency read, results are expected today, and those results are expected to be minimal."
The patient and all personnel involved were surveyed after the incident and readings were at background levels.
Notified R1DO (Dentel) and NMSS Event Notifications (email).
* * * UPDATE ON 5/12/20 AT 1158 EDT FROM JOHN CHIPPO TO JEFFREY WHITED * * *
The following information was received via email:
"The preliminary dosimetry report indicates three staff members involved in the event. The technologist received 4 mrem whole body dose, the authorized user received 3 mrem whole body dose and the AMP received 3 mrem whole body dose and a 15 mrem dose on their finger dosimeter. No other dose information was received at this time."
Notified R1DO (Lally) and NMSS Event Notifications (email).
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 information was received via email:
"The Department [Pennsylvania Bureau of Radiation Protection] received notification from a licensee on May 5, 2020, of a medical event involving a Varian GammMedplus iX high dose rate remote afterloader (HDR) containing 8.6 Ci of iridium 192. The patient was set to receive 10 fractions (channels) of breast cancer treatment. An error was noted when treatment from the third channel was attempted. The source was retracted back into the safe position upon the error indication. Staff reset the unit and rebooted. The unit functioned normally for the fourth channel. During the fifth channel the machine experienced another fault, but the source did not automatically retract. Staff then attempted two emergency stop procedures; however, both failed. Staff were finally able to manually retract the source after approximately two to four minutes; however, it hasn't been determined if the source was completely retracted into the shielded safe on the HDR due to catheter interference. The patient was quickly disconnected from the catheter, everyone was immediately removed, and the room was secured from entry. No dose is expected outside the HDR room as it is housed within an accelerator vault. The manufacturer has been contacted. The licensee has also requested the log files from the manufacturer for dose reconstruction of those involved. The department is currently in contact with the licensee and will update this event as soon as more information is provided."
PA Event Report ID No: PA200011
* * * UPDATE ON 5/7/20 AT 1208 EDT FROM JOHN CHIPPO TO ANDREW WAUGH * * *
The following information was received via email:
"Manufacturer service technicians removed the wire/source from the afterloader on 5/6/2020. Preliminarily, it appears the source became stuck approximately 4 to 5 inches from the shielded park position (inside the afterloader, but outside the shielded safe). Dosimetry badges have been sent for emergency read, results are expected today, and those results are expected to be minimal."
The patient and all personnel involved were surveyed after the incident and readings were at background levels.
Notified R1DO (Dentel) and NMSS Event Notifications (email).
* * * UPDATE ON 5/12/20 AT 1158 EDT FROM JOHN CHIPPO TO JEFFREY WHITED * * *
The following information was received via email:
"The preliminary dosimetry report indicates three staff members involved in the event. The technologist received 4 mrem whole body dose, the authorized user received 3 mrem whole body dose and the AMP received 3 mrem whole body dose and a 15 mrem dose on their finger dosimeter. No other dose information was received at this time."
Notified R1DO (Lally) and NMSS Event Notifications (email).
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.