Event Notification Report for April 16, 2025

AGREEMENT STATE REPORT - FAILURE OF EXIT PORTAL MONITOR

The following report was received by the Illinois Emergency Management Agency (the Agency) via phone and email:

"The corporate radiation safety officer for Isomedix Operations, Inc. (IL-01123-02) contacted the Agency on 4/18/2025 to report that during routine monthly testing of the exit portal monitor conducted on 4/17/2025, on the Co-60 pool irradiator (irradiator 192), the monitor failed to respond to radiation. The issue was immediately identified as corrosion on the cable-to-probe connection and was subsequently repaired, tested, and found to be functional. There was no report of exposure to personnel or loss of control. The licensee reported the failure within 24 hours as required by 346.830(a) and will submit a written report within 30 days as required."

Illinois Item Number: IL250017

AGREEMENT STATE REPORT - EQUIPMENT FAILURE

The following information was provided by the Pennsylvania Bureau of Radiation Protection (the Department) via email:

"On April 16, 2025, the University of Pittsburgh informed the Department of an equipment failure event involving its microSelection HDR [high dose-rate] device. It is reportable under 10 CFR 30.50(b)(2).
"A patient was receiving an iridium-192 treatment using an Elekta, Inc. microSelectron HDR 106.990. During the treatment, a software error occurred, and the computer shut off. This stopped the treatment and retracted the source into the safe/shielded position. The Elekta service engineer was immediately contacted, and a system reboot was performed to bring the HDR machine and computer back to functional status. The authorized user decided to continue treatment with the service engineer remaining immediately available via telephone. After the treatment was resumed, the source was deployed (as verified by room radiation monitor, source indicator at machine console computer, and sound of source movement) but the computer screen did not indicate treatment in progress by visual display and again gave an error message (`software problem detected'). The authorized medical physicist pressed the emergency button and the source was retracted. Per the authorized user physician, the patient's treatment was terminated for the day. Elekta personnel arrived on 4/17/25 and created 1 GB [Gigabyte] space on the local drive for a temporary solution, then permitted UPMC IT [University of Pittsburgh Medical Center Information Technology] personnel to assist. The UPMC IT personnel came onsite and created 230 GB local drive space, which is confirmed to be enough for the long term. Elekta personnel did note that treatment volumes for this location (which require more memory) are exceptionally high compared to other Elekta brachytherapy clinics.

"The cause of this event was possibly a generic issue with insufficient storage space availability, the software error occurred during treatment and the treatment data was not able to be stored in the database, which led to failure.
"The Department will perform a reactive inspection."

Pennsylvania Event Report Number: PA250006

AGREEMENT STATE REPORT - STUCK SOURCE

The following is a summary of information provided by the Arkansas Department of Health via email:

On Thursday, April 17, 2025, at 1309 CDT, the licensee submitted a notification that on Wednesday, April 16, 2025, at 1730 CDT, they had experienced a radiography source failure to retract. The radiation safety officer (RSO) was notified. They arrived onsite at 1930 CDT with retrieval tools and shielding and was able to retract the source into the camera by 2330 CDT. The location was in an isolated area of the Union Pacific rail yard with concrete abutments that afforded shielding of the source. Exposures were limited to 134 millirem to the RSO, 36 millirem to the radiographer, and 11 millirem to the trainee. There was no exposure to the public.

The exposure device is a SPEC 150, serial number 2240, with a SPEC model G-60 source, serial number FL1805, with 33 curies of Ir-192.

The cause was determined to be a kink or crimp in the guide tubing preventing the source from retracting. The investigation is ongoing, and reporting will proceed in accordance with SA-300.

Arkansas Event Number: AR-2025-002

EN Revision Imported Date: 4/30/2025

EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT

The following report was received by the Pennsylvania Bureau of Radiation Protection [the Department] via email:

"On April 16, 2025, a patient was receiving an iridium-192 treatment using an Elekta, Inc. microSelectron HDR [high-dose remote afterloader]. During the procedure, a software error that retracted the source occurred. The unit was rebooted, and the treatment was restarted. However, 17 seconds into restarting, the unit failed to show the next dwell position, so the treatment was terminated. Approximately 48 percent of the prescribed dose was administered to the patient. No harm is expected to the patient and both the physician and patient were notified. The patient treatment plan will be updated accordingly.

"The official cause is still under investigation. The service engineer will be onsite April 17, 2025, to troubleshoot the HDR. The Department will perform a reactive inspection. More information will be provided as received."

Pennsylvania Event Report Number: PA250004

* * * RETRACTION ON 04/29/2025 AT 1254 EDT FROM JOHN S. CHIPPO TO TROY JOHNSON * * *

The following report was received by the Pennsylvania Bureau of Radiation Protection via email:

"On April 16, 2025, a patient was receiving an iridium-192 treatment using an Elekta, Inc. microSelectron HDR 106.990 [high-dose remote afterloader]. Initially, it was reported that they received 48 percent of the fractionated dose prescribed, however, an Elekta service engineer was onsite on April 17, 2025, to troubleshoot the HDR. They determined that, based on the true delivery time, verified via machine detailed logfiles, the patient received 73 percent of the planned treatment dose during this fraction (the patient was prescribed 7.0 Gy and received 5.1 Gy). Since the patient dose for this fraction delivered did not differ from the prescribed dose by 50 percent or more, this event does not meet the qualifications for reporting."

Notified R1DO (Lally), and NMSS Events Notification (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.