ENS 46512: Difference between revisions
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| event date = 12/22/2010 12:30 MST | | event date = 12/22/2010 12:30 MST | ||
| last update date = 12/27/2010 | | last update date = 12/27/2010 | ||
| title = Agreement State Report Involving | | title = Agreement State Report Involving an Hdr Misadministration | ||
| event text = The following report was received from the State of Arizona via fax: | | event text = 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. | 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. | ||
Revision as of 22:08, 1 March 2018
| Where | |
|---|---|
| Banner Good Samaritan Medical Center Phoenix, Arizona (NRC Region 4) | |
| License number: | Az 07-478 |
| Organization: | Arizona Radiation Regulatory Agency |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+111.72 h4.655 days <br />0.665 weeks <br />0.153 months <br />) | |
| Opened: | Aubrey V. Goodwin 11:13 Dec 27, 2010 |
| NRC Officer: | Steve Sandin |
| Last Updated: | Dec 27, 2010 |
| 46512 - NRC Website | |