ENS Event | |
|---|---|
07:00 Sep 1, 2023 | |
| Title | Dose Misadministration |
| Event Description | The following information was provided by the Arizona Department of Health Services (the Department) via email:
The Department was notified by the licensee that on September 1, 2023, a patient was prescribed 1,800 centigray in 3 fractions using a 2.5 cm diameter vaginal cylinder. After the start of the first fraction of the treatment, the patient notified the Authorized User and Authorized Medical Physicist that she thought the cylinder was in the `wrong place.' The treatment was stopped at 111 seconds into the treatment and the licensee discovered that the cylinder was placed into the rectum instead of the vagina. The treatment utilized a Varian GammaMedplus iX with an approximate 5.2 Ci Ir-192 source. The Department has requested additional information and continues to investigate the event. 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 | |
|---|---|
| Verde Valley Medical Center Sedona, Arizona (NRC Region 4) | |
| License number: | 13 - 035 |
| Organization: | Arizona Dept Of Health Services |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+11.88 h0.495 days <br />0.0707 weeks <br />0.0163 months <br />) | |
| Opened: | Brian D. Goretzki 18:53 Sep 1, 2023 |
| NRC Officer: | Ernest West |
| Last Updated: | Sep 1, 2023 |
| 56709 - NRC Website | |
Verde Valley Medical Center with Agreement State | |
WEEKMONTHYEARENS 567092023-09-01T07:00:0001 September 2023 07:00:00
[Table view]Agreement State Dose Misadministration 2023-09-01T07:00:00 | |