ENS 45165

v t e ENS Event
05:00 Jun 25, 2009
Title	Agreement State Report Involving Medical Event
Event Description	The following information was provided by the State of Wisconsin via email: On June 26, 2009, the Radiation Safety Officer (RSO) notified DHS of a probable medical event that occurred on June 25, 2009 involving an HDR treatment to the esophagus. The authorized user intended to insert the applicator 2 cm past the distal part of the esophageal tumor. A GI specialist verified the location prior to treatment using a scope. Post treatment location of the applicator was reviewed using an AP lateral film. It was then realized that the applicator went 10 cm too far. The prescribed dose was 500 cGy. Therefore, a dose was given to a organ or tissue other than the intended treatment site that exceeds 0.5 Sv (50 rem) to an organ or tissue, and was 50% or more of the dose expected from the administration defined in the written directive (DHS 157.72(1)(a)(3.). DHS inspectors will investigate June 29, 2009. Wisconsin Incident Number: WI090005 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 45165 +/-
Where
Wheaton Franciscan Healthcare - St. Joseph Milwaukee, Wisconsin (NRC Region 3)
License number:	079-1288-01
Organization:	Wisconsin Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+31.18 h1.299 days <br />0.186 weeks <br />0.0427 months <br />)
Opened:	Diana Sulas 12:11 Jun 26, 2009
NRC Officer:	John Knoke
Last Updated:	Jun 26, 2009
45165 - NRC Website
v • d • e

v t e Emergency Notification System
Wheaton Franciscan Healthcare - St. Joseph with Agreement State
WEEKMONTHYEAR2009-06-25T05:00:00 [Table view]
[ENS list for Wheaton Franciscan Healthcare - St. Joseph]

Navigation menu