Event Notification Report for October 03, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/02/2022 - 10/03/2022
Hospital
Event Number: 56139
Rep Org: Henry Ford Hospital
Licensee: Henry Ford Hospital
Region: 3
City: Detroit State: MI
County:
License #: 21-04-109-16
Agreement: N
Docket:
NRC Notified By: Alan Jackson
HQ OPS Officer: Kerby Scales
Licensee: Henry Ford Hospital
Region: 3
City: Detroit State: MI
County:
License #: 21-04-109-16
Agreement: N
Docket:
NRC Notified By: Alan Jackson
HQ OPS Officer: Kerby Scales
Notification Date: 10/04/2022
Notification Time: 14:57 [ET]
Event Date: 10/03/2022
Event Time: 12:10 [EDT]
Last Update Date: 10/04/2022
Notification Time: 14:57 [ET]
Event Date: 10/03/2022
Event Time: 12:10 [EDT]
Last Update Date: 10/04/2022
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(3) - Dose To Other Site > Specified Limits
10 CFR Section:
35.3045(a)(3) - Dose To Other Site > Specified Limits
Person (Organization):
Betancourt-Roldan, Diana (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Betancourt-Roldan, Diana (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MEDICAL EVENT - INCORRECT WRITTEN DIRECTIVE
The following information was provided by the licensee via phone:
On 10/3/22, a medical event occurred when a written directive was incorrect. The nuclear medicine staff recognized the written directive was incorrect and delivered the correct dose to the proper location. The patient was not harmed.
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 provided by the licensee via phone:
On 10/3/22, a medical event occurred when a written directive was incorrect. The nuclear medicine staff recognized the written directive was incorrect and delivered the correct dose to the proper location. The patient was not harmed.
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.
Agreement State
Event Number: 56142
Rep Org: NJ Rad Prot And Rel Prevention Pgm
Licensee: JFK Medical Center
Region: 1
City: Edison State: NJ
County:
License #: 441325
Agreement: Y
Docket:
NRC Notified By: Richard Peros
HQ OPS Officer: Kerby Scales
Licensee: JFK Medical Center
Region: 1
City: Edison State: NJ
County:
License #: 441325
Agreement: Y
Docket:
NRC Notified By: Richard Peros
HQ OPS Officer: Kerby Scales
Notification Date: 10/04/2022
Notification Time: 15:56 [ET]
Event Date: 10/03/2022
Event Time: 00:00 [EDT]
Last Update Date: 10/04/2022
Notification Time: 15:56 [ET]
Event Date: 10/03/2022
Event Time: 00:00 [EDT]
Last Update Date: 10/04/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Young, Matt (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Young, Matt (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - INADVERTENT PAUSE IN TREATMENT
The following was received from the state of New Jersey via email:
"While treating a patient with a gamma-knife icon unit, there was an apparent activation of the emergency stop. No one admits to touching the emergency stop button, but the sources retracted, the unit doors remained open, and the table functions were frozen. One of the authorized medical physicists (AMP) entered the room and manually retracted the table from the unit, as per emergency procedures. The licensee reported that this is the protocol when the emergency (red) console button is pushed. The AMP and one of the authorized users (AU) helped the patient off the table. The couch lever was pushed back into place and the unit was reset so the doors would close.
"The AMP observed the treatment time at the back of the unit. The AMP repeated the sector position check of the unit without incident. The licensee contacted the device manufacturer, Elekta, about the incident. They reported that Elekta informed them it was acceptable to proceed and complete the patient treatment. They then resumed and completed the patient's treatment without further incident. The events were documented in the patient's record.
"The manufacturer sent a service technician to the licensee the next day (i.e., today, October 4, 2022) to inspect the unit, make any needed repairs and check the log files. After review of the logs, the AMP and Elekta believe patient movement triggered the incident. The dose to the AMP and AU was estimated to be 0.134 mrem. This was not a medical event, since the planned treatment was completed."
The following was received from the state of New Jersey via email:
"While treating a patient with a gamma-knife icon unit, there was an apparent activation of the emergency stop. No one admits to touching the emergency stop button, but the sources retracted, the unit doors remained open, and the table functions were frozen. One of the authorized medical physicists (AMP) entered the room and manually retracted the table from the unit, as per emergency procedures. The licensee reported that this is the protocol when the emergency (red) console button is pushed. The AMP and one of the authorized users (AU) helped the patient off the table. The couch lever was pushed back into place and the unit was reset so the doors would close.
"The AMP observed the treatment time at the back of the unit. The AMP repeated the sector position check of the unit without incident. The licensee contacted the device manufacturer, Elekta, about the incident. They reported that Elekta informed them it was acceptable to proceed and complete the patient treatment. They then resumed and completed the patient's treatment without further incident. The events were documented in the patient's record.
"The manufacturer sent a service technician to the licensee the next day (i.e., today, October 4, 2022) to inspect the unit, make any needed repairs and check the log files. After review of the logs, the AMP and Elekta believe patient movement triggered the incident. The dose to the AMP and AU was estimated to be 0.134 mrem. This was not a medical event, since the planned treatment was completed."