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Event Notification Report for September 23, 2020

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Event Reports For
9/22/2020 - 9/23/2020

** EVENT NUMBERS **


54899

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Agreement State Event Number: 54899
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: Memorial Hermann Health System
Region: 4
City: Houston   State: TX
County:
License #: L06439
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Brian P. Smith
Notification Date: 09/15/2020
Notification Time: 12:08 [ET]
Event Date: 09/01/2020
Event Time: 00:00 [CDT]
Last Update Date: 09/15/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
CALE YOUNG (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE DURING MEDICAL TREATMENT

The following information was received via e-mail from the Texas Department of State Health Services (the Agency):

"On September 14, 2020, the Agency was notified by the licensee's radiation safety officer (RSO) that they had discovered a medical event [occurred September 1, 2020] involving a Varian high dose rate remote afterloader (HDR) unit had occurred. The RSO reported that a patient was to receive two boost treatments using the HDR unit. While setting up for the second treatment, the licensee noted the length of source catheter tube used in the first treatment was incorrect, therefore only part of the intended target was treated. The RSO stated the patient and physician were both notified of the event and that the current plan is to perform an additional treatment to the area that was under exposed in the first treatment. The RSO stated they did not expect any adverse effects to the patient. The Agency has requested additional information on the event. Additional information will be provided as it is received in accordance with SA-300."

Texas Incident Number: 9796

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.


Page Last Reviewed/Updated Wednesday, September 23, 2020
Wednesday, September 23, 2020