ENS 44895

v t e ENS Event
05:00 Mar 9, 2009
Title	Agreement State Report - Prostate Brachytherapy Overdose
Event Description	The Wisconsin Radiation Protection Section (RPS) was notified on 3/10/09 of a possible medical event that occurred on 3/9/09. The medical event occurred at Lombardi Cancer Center, which is affiliated with Aurora Health Center in Sheboygan (RML #117-1022-01). The treatment was a permanent prostate brachytherapy implant using I-125 seeds. The intended total dose was 107 Gy and the patient was administered a total dose of 144 Gy. The overdose was discovered on 3/9/09, following review by the dosimetrist. The patient was notified on 3/10/09. The referring urologist and the patient's primary care provider were also notified. RPS has had telephone communications with the RSO and the Authorized User (AU) and has requested additional documents. The RSO will be unavailable (out-of-town). A team of RPS staff will be conducting a site visit at the facility when the AU returns. Wisconsin Radiation Protection Section Event Report ID Number: WI090003. An on-site investigation is planned by Wisconsin Radiation Protection Section beginning 3/12/09. A follow-up report will be issued after the investigation is completed. 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 44895 +/-
Where
Aurora Health Center Sheboygan, Wisconsin (NRC Region 3)
License number:	117-1022-01
Organization:	Wisconsin Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+57 h2.375 days <br />0.339 weeks <br />0.0781 months <br />)
Opened:	Leola Dekock 14:00 Mar 11, 2009
NRC Officer:	Donald Norwood
Last Updated:	Mar 11, 2009
44895 - NRC Website
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v t e Emergency Notification System
Aurora Health Center with Agreement State
WEEKMONTHYEAR2009-03-09T05:00:00 [Table view]
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