ENS 46501

v t e ENS Event
06:00 Aug 12, 2008
Title	Agreement State Report - Medical Event- Prostate Brachytherapy Treatment Underdose
Event Description	This information was emailed by the state as follows: In July 2010, the Wisconsin Department of Health Services (DHS) sent out an Information Notice to all licensees who perform prostate brachytherapy and asked them to perform a retrospective review of all prostate brachytherapy cases to determine whether any medical events had occurred. On December 20, 2010, the licensee's Radiation Safety Officer notified DHS that on August 12, 2008 a patient received only 75.4 % of the prescribed dose during prostate brachytherapy using I-125 seeds. The patient was prescribed 145 Gy to the prostate, and based on a CT scan performed thirty days post-surgery, the licensee determined that the treatment delivered only 109.3 Gy to the prostate. The authorized user who treated this patient is no longer at the licensee's facility. The licensee is complying with the reporting criteria in DHS 157.72(1)(e) concerning notifications to the patient and referring physician. The licensee has already made process improvements (i.e. planning to higher D90 values) which have resulted in improved dosimetric coverage. DHS inspectors will follow up on the next routine inspection. Event Report ID # WI100019 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 46501 +/-
Where
Mercy Medical Center Oshkosh, Wisconsin (NRC Region 3)
License number:	139-1177-01
Organization:	Wisconsin Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+20669.5 h861.229 days <br />123.033 weeks <br />28.313 months <br />)
Opened:	Megan Shober 12:30 Dec 21, 2010
NRC Officer:	John Knoke
Last Updated:	Dec 21, 2010
46501 - NRC Website
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v t e Emergency Notification System
Mercy Medical Center with Agreement State
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