ENS Event | |
|---|---|
18:00 Dec 27, 2006 | |
| Title | Wisconsin Agreement State Report |
| Event Description | Event Location: University of Wisconsin Hospital, 600 Highland Avenue, Madison, Wisconsin 53792
The event occurred on Wednesday, December 27, 2006. A patient was to receive 4 high dose-rate brachytherapy fractions of 5 Gy each over a 7 cm length of the vaginal mucosa using a vaginal cylinder. About halfway through the first treatment fraction, the actual dose delivered to part of the target organ, over the inferior 3 cm of the treatment length, exceeded the prescribed dose by more than 50%, (range 1.5 - 2.37 times the prescribed dose). The biological dose to the patient from this event was under the prescribed dose. The subsequent 3 fractions will be modified to deliver the intended biological dose to the patient, and no adverse health effects are expected to the patient. Notification, by the licensee, of this event to the Department of Health and Family Services (DHFS) occurred on Thursday, December 28, 2006. DHFS will dispatch a team on Monday, January 8, 2007 to investigate this event. Event Report ID No: WI-07-01 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. |
| Where | |
|---|---|
| Univ. Of Wisconsin Hospital At Madison Madison, Wisconsin (NRC Region 3) | |
| License number: | 25-1323-01 |
| Organization: | Wisconsin Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+185.55 h7.731 days <br />1.104 weeks <br />0.254 months <br />) | |
| Opened: | Jason Hunt 11:33 Jan 4, 2007 |
| NRC Officer: | John Mackinnon |
| Last Updated: | Jan 4, 2007 |
| 43074 - NRC Website | |
Univ. Of Wisconsin Hospital At Madison with Agreement State | |
WEEKMONTHYEARENS 430742006-12-27T18:00:00027 December 2006 18:00:00
[Table view]Agreement State Wisconsin Agreement State Report 2006-12-27T18:00:00 | |