ENS 45999

v t e ENS Event
05:00 Jun 10, 2010
Title	Agreement State Report - Brachytherapy Dose Received Was Greater than 20% of Prescribed Dose
Event Description	The following was received from the State via fax: On June 9, 2010, the Radiation Safety Officer (RSO) reported that earlier that day a patient undergoing an intravascular brachytherapy procedure was administered a dose to the coronary artery exceeding the prescribed dose by more than 20%. This is a medical event as described in DHS 157.72(1)(a)1. The prescribed dose was 18.4 Gy; the dose delivered was 23 Gy. The treatment device is a Novoste Beta-Cath intravascular brachytherapy device containing Sr-90. The overdose was identified during the post-planning for the procedure. The treatment time for this procedure is based on the measured diameter of the coronary artery. Depending on the diameter, one or three treatment times is selected; in this case the wrong treatment time was selected. The RSO stated that this treatment time is supposed to be independently reviewed and approved on the written directive, which is to be signed by the authorized user. The written directive was not signed by the authorized user prior to administration. [Wisconsin] DHS inspectors will investigate this medical event on June 11, 2010. Event Report No.: WI100008 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 45999 +/-
Where
Medical College Of Wisconsin Wisconsin (NRC Region 3)
License number:	079-1104-01
Organization:	Wisconsin Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+6.3 h0.263 days <br />0.0375 weeks <br />0.00863 months <br />)
Opened:	Emily Eggers 11:18 Jun 10, 2010
NRC Officer:	Joe O'Hara
Last Updated:	Jun 10, 2010
45999 - NRC Website
v • d • e

v t e Emergency Notification System
Medical College Of Wisconsin with Agreement State
WEEKMONTHYEAR2023-03-09T06:00:00 [Table view]
[ENS list for Medical College Of Wisconsin]

Navigation menu