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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 46512 | 22 December 2010 19:30:00 | Agreement State | Agreement State Report Involving an Hdr Misadministration | 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. |