ENS 45978

v t e 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. * * UPDATE FROM CARL SULLIVAN TO PETE SNYDER ON 6/10/10 AT 1156 EDT * * * 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.

ENS 45978 +/-
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
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Lovelace Medical Center with Agreement State
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