Event Notification Report for October 20, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/19/2023 - 10/20/2023
Agreement State
Event Number: 56805
Rep Org: Florida Bureau of Radiation Control
Licensee: Florida Cancer Spec. & Res. Inst.
Region: 1
City: Orlando State: FL
County:
License #: 3897-2
Agreement: Y
Docket:
NRC Notified By: John A. Williamson
HQ OPS Officer: Lawrence Criscione
Licensee: Florida Cancer Spec. & Res. Inst.
Region: 1
City: Orlando State: FL
County:
License #: 3897-2
Agreement: Y
Docket:
NRC Notified By: John A. Williamson
HQ OPS Officer: Lawrence Criscione
Notification Date: 10/20/2023
Notification Time: 12:44 [ET]
Event Date: 10/20/2023
Event Time: 00:00 [EDT]
Last Update Date: 10/20/2023
Notification Time: 12:44 [ET]
Event Date: 10/20/2023
Event Time: 00:00 [EDT]
Last Update Date: 10/20/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Jackson, Don (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Jackson, Don (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - PATIENT OVEREXPOSURE
The following information was provided by the Florida Bureau of Radiation Control [the Bureau] via email:
"This is a medical event resulting from an overexposure of the breast. A 52-year old female was being treated with 10 fractions of High Dose Rate I-192. The total dose was to be 34 Gy total. The estimated actual dose was 30 percent greater. The delivery system is on a windows XP based personal computer and due to computer security, a windows XP based computer cannot be on the network. Because of this [configuration], the planning and delivery systems are not linked. [As a result,] staff did not verify the dwell times between the planning and delivery systems, resulting in using an incorrect dwell time. Eight (8) fractions were delivered with incorrect dwell time before this was noted."
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 Florida Bureau of Radiation Control [the Bureau] via email:
"This is a medical event resulting from an overexposure of the breast. A 52-year old female was being treated with 10 fractions of High Dose Rate I-192. The total dose was to be 34 Gy total. The estimated actual dose was 30 percent greater. The delivery system is on a windows XP based personal computer and due to computer security, a windows XP based computer cannot be on the network. Because of this [configuration], the planning and delivery systems are not linked. [As a result,] staff did not verify the dwell times between the planning and delivery systems, resulting in using an incorrect dwell time. Eight (8) fractions were delivered with incorrect dwell time before this was noted."
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: 56807
Rep Org: Texas Dept of State Health Services
Licensee: The Methodist Hospital (Houston)
Region: 4
City: Houston State: TX
County:
License #: L00457
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Lawrence Criscione
Licensee: The Methodist Hospital (Houston)
Region: 4
City: Houston State: TX
County:
License #: L00457
Agreement: Y
Docket:
NRC Notified By: Art Tucker
HQ OPS Officer: Lawrence Criscione
Notification Date: 10/20/2023
Notification Time: 16:52 [ET]
Event Date: 10/20/2023
Event Time: 00:00 [CDT]
Last Update Date: 10/20/2023
Notification Time: 16:52 [ET]
Event Date: 10/20/2023
Event Time: 00:00 [CDT]
Last Update Date: 10/20/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
O'Keefe, Neil (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
O'Keefe, Neil (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - UNSHIELDED SOURCE
The following information was provided by the Texas Department of State Health Services (the Department) via email:
"On October 20, 2023, the Department was notified by the licensee's radiation safety officer (RSO) that a 52 millicurie (current activity) strontium - 90 source could not be returned to the fully shielded position in a Novoste brachytherapy device. The source had been retracted from the patient, therefore the patient had received the prescribed dose. The therapist followed the licensee's emergency procedure and placed the device into a plastic box and took it to their hot lab. Once in the hot lab, they were able to fully retract the source. The device has been taken out of service. The RSO stated the vender has been notified of the event. No overexposures occurred due to this event."
Texas Incident Number: 10060
Texas NMED Number: TX230048
The following information was provided by the Texas Department of State Health Services (the Department) via email:
"On October 20, 2023, the Department was notified by the licensee's radiation safety officer (RSO) that a 52 millicurie (current activity) strontium - 90 source could not be returned to the fully shielded position in a Novoste brachytherapy device. The source had been retracted from the patient, therefore the patient had received the prescribed dose. The therapist followed the licensee's emergency procedure and placed the device into a plastic box and took it to their hot lab. Once in the hot lab, they were able to fully retract the source. The device has been taken out of service. The RSO stated the vender has been notified of the event. No overexposures occurred due to this event."
Texas Incident Number: 10060
Texas NMED Number: TX230048