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. |
| 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 | |
Wheaton Franciscan Healthcare - St. Joseph with Agreement State | |
WEEKMONTHYEARENS 451652009-06-25T05:00:00025 June 2009 05:00:00
[Table view]Agreement State Agreement State Report Involving Medical Event 2009-06-25T05:00:00 | |