ENS Event | |
|---|---|
06:00 May 4, 2010 | |
| Title | Agreement State Report - Medical Misadministration |
| Event Description | A patient was treated in early May with a vaginal applicator using three doses of High Dose Rate (HDR) brachytherapy. On May 11, 2010, the patient contacted the doctor's office and complained of skin irritation to her leg. On May 18, 2010, the patient again called to report continued skin irritation. On both of these dates, the patient could not come in to see the doctor. On May 26, 2010, the patient was seen by the doctor and radiation irritation was evident on her leg. Initial estimates of the leg dose are greater than 50 REM. Both the patient and doctor have been notified of this event.
The source was Yttrium (unknown strength). [See correction below] The State is investigating this event.
The event date in the header was corrected to 5/4/10. The source was Ir-192 with an activity of 3506.34 mCi on 5/4/10. The State continues to investigate this event. Notified R4DO (Shannon) and FSME (Villamar). 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. |
| Where | |
|---|---|
| Lovelace Medical Center Albuquerque, New Mexico (NRC Region 4) | |
| License number: | MI 210 94 |
| Organization: | New Mexico Rad Control Program |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+753.33 h31.389 days <br />4.484 weeks <br />1.032 months <br />) | |
| Opened: | Carl Sullivan 15:20 Jun 4, 2010 |
| NRC Officer: | Mark Abramovitz |
| Last Updated: | Jun 10, 2010 |
| 45978 - NRC Website | |
Lovelace Medical Center with Agreement State | |
WEEKMONTHYEARENS 576072025-03-14T06:00:00014 March 2025 06:00:00
[Table view]Agreement State Medical Event ENS 573202024-07-18T06:00:00018 July 2024 06:00:00 Agreement State Y-90 Dose Misadministration ENS 459782010-05-04T06:00:0004 May 2010 06:00:00 Agreement State Agreement State Report - Medical Misadministration 2025-03-14T06:00:00 | |