ENS Event | |
|---|---|
07:00 Aug 25, 2025 | |
| Title | Medical Event |
| Event Description | The following information was provided by the Arizona Department of Health Services (the Department) via email:
On September 3, 2025, the Department received notification from the licensee about a medical event involving a high dose rate treatment that occurred on August 25, 2025. The event was discovered on September 2, 2025, when the patient returned for a subsequent [fractional treatment]. A written directive was created to deliver 4,000 cGy over 8 fractions to a scalp lesion with a 30 mm Valencia skin applicator. [A patient treatment simulation was conducted] on August 20, 2025, where the radiation therapist constructed a brain mask for immobilization that included an opening at the top of the head. This was done to allow placement of the skin applicator. On August 25, 2025, the authorized user identified a lesion that was superior to the lesion he had intended to treat, which was not biopsied. The wrong site was treated with 500 cGy by a 7.54 Ci Ir-192 source. The Department has requested additional information and continues to investigate the event. AZ Incident Number: 25-016 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. |
| Where | |
|---|---|
| Banner University Medical Center Tucson, Arizona (NRC Region 4) | |
| License number: | 10-044 |
| Organization: | Arizona Dept Of Health Services |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+234.97 h9.79 days <br />1.399 weeks <br />0.322 months <br />) | |
| Opened: | Brian Goretzki 01:58 Sep 4, 2025 |
| NRC Officer: | Robert A. Thompson |
| Last Updated: | Sep 4, 2025 |
| 57897 - NRC Website | |
Banner University Medical Center with Agreement State | |
WEEKMONTHYEARENS 578972025-08-25T07:00:00025 August 2025 07:00:00
[Table view]Agreement State Medical Event ENS 565992023-06-29T07:00:00029 June 2023 07:00:00 Agreement State Medical Misadministration ENS 562182022-11-10T07:00:00010 November 2022 07:00:00 Agreement State Patient Underdose 2025-08-25T07:00:00 | |