ENS Event | |
|---|---|
05:00 Sep 9, 2010 | |
| Title | Agreement State Report - Delivered Dose Is Different from the Prescribed Dose |
| Event Description | The following information was received by facsimile:
On September 14, 2010, the Department [Wisconsin Department of Health Services] received a facsimile from the licensee's Radiation Safety Officer (RSO) that a medical event occurred on September 9, 2010, involving a permanent implant of I-125 seeds for a prostate manual brachytherapy procedure where the total dose delivered differs from the prescribed dose by 20% or more. This is a medical event as described in DHS 157.72(1)(a)1. The prescribed dose was 145 Gy; the dose delivered was 80 Gy. The licensee uses D80 < 80% as their dose based criteria for determining medical events. Using the licensee's dose based criteria of D80 < 80% the dose received by the prostate was 55% of the intended dose. The underdose was identified during the post-implant planning for the procedure. The RSO indicated that the possible cause was the maximum insertion depth was 0.6 cm below the base of the prostate gland and all needles were implanted distal to the base resulting in the area being 'cold'. Possible corrective actions are under review by the licensee's staff and a one month post-implant CT is planned to determine the impact to the patient. [Department] inspectors will investigate this medical event on September 16, 2010. Wisconsin Event Report: WI100015 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 | |
|---|---|
| Marshfield Clinic Weston, Wisconsin (NRC Region 3) | |
| License number: | 141-1162-01 |
| Organization: | Wisconsin Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+127.95 h5.331 days <br />0.762 weeks <br />0.175 months <br />) | |
| Opened: | Chris Timmerman 12:57 Sep 14, 2010 |
| NRC Officer: | Vince Klco |
| Last Updated: | Sep 14, 2010 |
| 46249 - NRC Website | |
Marshfield Clinic with Agreement State | |
WEEKMONTHYEARENS 560822022-08-10T05:00:00010 August 2022 05:00:00
[Table view]Agreement State Lost Y-90 Microspheres ENS 508232015-02-13T06:00:00013 February 2015 06:00:00 Agreement State Agreement State Report - Gamma Knife Unit Failed to Function as Designed ENS 462492010-09-09T05:00:0009 September 2010 05:00:00 Agreement State Agreement State Report - Delivered Dose Is Different from the Prescribed Dose ENS 460822010-07-09T05:00:0009 July 2010 05:00:00 Agreement State Agreement State - Brachytherapy Treatment Dose Delivered Differs from Prescribed ENS 414202005-02-16T06:00:00016 February 2005 06:00:00 Agreement State Agreement State Medical Event 2022-08-10T05:00:00 | |