ENS 57757

v t e 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.

ENS 57757 +/-
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
v • d • e

v t e Emergency Notification System
Arizona Center For Cancer Care with Agreement State
WEEKMONTHYEAR2025-06-10T07:00:00 [Table view]
[ENS list for Arizona Center For Cancer Care]

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