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. |
| 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 | |
Mercy Medical Center with Agreement State | |
WEEKMONTHYEARENS 487802013-01-17T06:00:00017 January 2013 06:00:00
[Table view]Agreement State Agreement State Report - Prostate Seed Implant Underdose ENS 466092011-02-10T06:00:00010 February 2011 06:00:00 Agreement State Agreement State Report - Leaking Mamosite Balloon Catheter Possibly Affected Dose ENS 459112010-04-29T06:00:00029 April 2010 06:00:00 Agreement State Agreement State Report - Potential Dose to Embryo or Fetus ENS 465012008-08-12T06:00:00012 August 2008 06:00:00 Agreement State Agreement State Report - Medical Event- Prostate Brachytherapy Treatment Underdose 2013-01-17T06:00:00 | |