ENS 41827

v t e ENS Event
05:00 Jul 6, 2005
Title	Wisconsin Agreement State Report - Medical Event
Event Description	The State provided the following information via email: On July 6, 2005, a brachytherapy procedure to treat a bile duct carcinoma using 22 iridium-192 sources totaling 53.9 milliCuries in a ribbon with spacing of 0.5 centimeter between each source was performed. The ribbon was routed through the nasal gastric system to the treatment site (bile duct). A radiograph was taken of the source placement in the bile duct before releasing the patient to a hospital room. The radiograph verified the sources to be in the prescribed location. On July 7, 2005, a verification image was taken at 0850 and found that the radioactive sources had moved approximately 5 centimeters toward the gastrointestinal tract. The location of the sources was outside of the intended site. An attempt to reposition the source ribbon by the authorized user was unsuccessful. The authorized user amended the written directive and removed the sources at approximately 1300. The sources were placed in storage. The licensee notified the department on July 8, 2005. The Wisconsin Radiation Protection Section will investigate the medical event.

ENS 41827 +/-
Where
Aspirus - Wausau Hospital Wausau, Wisconsin (NRC Region 3)
License number:	073-1342-01
Organization:	Wisconsin Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+58.75 h2.448 days <br />0.35 weeks <br />0.0805 months <br />)
Opened:	Paul J. Caleb 15:45 Jul 8, 2005
NRC Officer:	Mike Ripley
Last Updated:	Jul 8, 2005
41827 - NRC Website
v • d • e

v t e Emergency Notification System
Aspirus - Wausau Hospital with Agreement State
WEEKMONTHYEAR2005-07-06T05:00:00 [Table view]
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