ENS 50548

v t e ENS Event
17:30 Oct 15, 2014
Title	Agreement State Report - Medical Event Due to Movement of Treatment Cylinder
Event Description	At approximately 1030 [MST] on October 15, 2014, the Agency [Arizona Radiation Regulatory Agency] was informed that the licensee had a medical event involving a High Dose Rate afterloader containing a 4.641 curie Iridium-192 source. A patient was receiving the third of three fractions involving a vaginal cylinder. When the Physicist entered the room after the treatment had concluded, he noticed that the cylinder had fallen out of the vaginal canal and was lying on the treatment table. The patient was unaware of the cylinders' position, but remembers feeling an 'oozing sensation' at the beginning of the treatment. The treatment time was for 431.3 seconds and the total prescribed dose for the fraction was 600 centigray and the total dose for all three fractions was 1800 centigray. The patient was also receiving external beam therapy at a rate of 200 centigray for 26 fractions, for a total dose of 5200 centigray. The patient received the last fraction on October 16th. The Agency is investigating the event. The Governor's office is being notified of this event. Arizona First Notice Event No.: 14-025 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 50548 +/-
Where
Arizona Oncology Associates Glendale, Arizona (NRC Region 4)
License number:	AZ 07-639
Organization:	Arizona Radiation Regulatory Agency
Reporting

Agreement State
Time - Person (Reporting Time:+42.77 h1.782 days <br />0.255 weeks <br />0.0586 months <br />)
Opened:	Aubrey Godwin 12:16 Oct 17, 2014
NRC Officer:	Jeff Rotton
Last Updated:	Oct 17, 2014
50548 - NRC Website
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v t e Emergency Notification System
Arizona Oncology Associates with Agreement State
WEEKMONTHYEAR2014-10-15T17:30:00 [Table view]
[ENS list for Arizona Oncology Associates]

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