ENS Event | |
|---|---|
07:00 Jun 10, 2025 | |
| Title | Medical Event |
| Event Description | The following information was received from the Arizona Department of Health Services (the Department) via email:
On June 11, 2025, the Department received notification from the licensee about a medical event occurring on June 10, 2025, involving a Nucletron Micro Selectron, Model 106.990, high dose rate (HDR) afterloader brachytherapy unit with a 10.4 Ci iridium-192 source. A patient was being treated for skin cancer on the right cheek and the prescription was for 4000 centigray (cGy) in 10 fractions of 400 cGy per fraction. The patient was treated on the left cheek for the first fraction. When the patient returned for the second treatment and the therapist was preparing them for treatment, the patient indicated that they thought the treatment should have been on the right cheek and not the left cheek. The authorized user immediately stopped the setup and verified that they had treated the wrong site. The Department has requested additional information and continues to investigate the event." Arizona Incident Number: 25-011 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 | |
|---|---|
| Arizona Center For Cancer Care Gilbert, Arizona (NRC Region 4) | |
| License number: | 07-615 |
| Organization: | Arizona Dept Of Health Services |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+35.85 h1.494 days <br />0.213 weeks <br />0.0491 months <br />) | |
| Opened: | Brian Goretzki 18:51 Jun 11, 2025 |
| NRC Officer: | Kerby Scales |
| Last Updated: | Jun 11, 2025 |
| 57757 - NRC Website | |
Arizona Center For Cancer Care with Agreement State | |
WEEKMONTHYEARENS 577572025-06-10T07:00:00010 June 2025 07:00:00
[Table view]Agreement State Medical Event ENS 551982021-04-16T07:00:00016 April 2021 07:00:00 Agreement State Leaking Sealed Source 2025-06-10T07:00:00 | |