ENS 46512

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v t e ENS Event
19:30 Dec 22, 2010
Title	Agreement State Report Involving an Hdr Misadministration
Event Description	The following report was received from the State of Arizona via fax: At approximately 12:30 PM December 22, 2010, the Licensee phoned the Agency [Arizona Radiation Regulatory Agency] to report an HDR [High Dose Radiation] misadministration. A breast cancer patient was undergoing treatment with a Nucletron MicroSelectron-HDR. A Savi-8 Accelerated Partial Breast Irradiation Device was connected to the HDR. This is manufactured by Cianno. The source apparently punched through the catheter and moved along the skin surface during the treatment. The patient did not notice the source was outside the tube. The source retracted normally to the shielded position. The physicist estimates that the patient's skin received 5 Gray if the source moved along the skins surface but if the source stuck in one position the patient's skin received 50 Gray. According to the licensee the catheter is easily kinked which can cause this failure. This has happened before but is the first time that this has resulted in an exposure. In the past, the licensee would repair the catheter with heat shrink tubing. The Agency continues to investigate the actions of the licensee. The U.S. NRC and the Arizona Governor's office have been notified of this event. Press coverage is not anticipated. Arizona First Notice: 10-016 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 46512 +/-
Where
Banner Good Samaritan Medical Center Phoenix, Arizona (NRC Region 4)
License number:	AZ 07-478
Organization:	Arizona Radiation Regulatory Agency
Reporting

Agreement State
Time - Person (Reporting Time:+111.72 h4.655 days <br />0.665 weeks <br />0.153 months <br />)
Opened:	Aubrey V. Goodwin 11:13 Dec 27, 2010
NRC Officer:	Steve Sandin
Last Updated:	Dec 27, 2010
46512 - NRC Website
v • d • e

v t e Emergency Notification System
Banner Good Samaritan Medical Center with Agreement State
WEEKMONTHYEAR2010-12-22T19:30:00 [Table view]
[ENS list for Banner Good Samaritan Medical Center]

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