ENS 56709

v t e 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.

ENS 56709 +/-
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
v • d • e

v t e Emergency Notification System
Verde Valley Medical Center with Agreement State
WEEKMONTHYEAR2023-09-01T07:00:00 [Table view]
[ENS list for Verde Valley Medical Center]

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