ENS 46574

From kanterella

Jump to navigation Jump to search

v t e ENS Event
06:00 Jan 26, 2011
Title	Agreement State Report - Prostate Brachytherapy Medical Underdose
Event Description	The following report was received via fax: On January 27, 2011, the licensee's Radiation Safety Officer reported the identification of three medical events that were discovered on January 26, 2011, involving permanent implants of Pd-103 for prostate brachytherapy where the total dose delivered differs from the prescribed dose by 20% or more. During a recent routine inspection, DHS [Wisconsin Department of Health Services] inspectors determined that the licensee was not reviewing prostate brachytherapy cases against the medical event criteria. The licensee established dose based criteria used by post-operation CT, prostate D90 values < 80% or >160% for classifying medical events. The licensee has evaluated all prostate implants performed since April 24, 2008. The licensee has notified the referring physicians and the referring physicians will not be notifying the patients. Case 1, November 2008: Prescribed dose 100 Gy. Prostate D90 was 77%. Case 2, April 2009: Prescribed dose 100 Gy. Prostate D90 was 71%. Case 3, October 2009: Prescribed dose 125 Gy. Prostate D90 was 78%. DHS inspectors are investigating these medical events and will send a special inspection team following the receipt of the licensee's 15 day report. Wisconsin Report Number: WI110003 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 46574 +/-
Where
Gunderson Clinic, Ltd La Crosse, Wisconsin (NRC Region 3)
License number:	063-1121-01
Organization:	Wisconsin Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+33.72 h1.405 days <br />0.201 weeks <br />0.0462 months <br />)
Opened:	Chris Timmerman 15:43 Jan 27, 2011
NRC Officer:	Mark Abramovitz
Last Updated:	Jan 27, 2011
46574 - NRC Website
v • d • e

v t e Emergency Notification System
Gunderson Clinic, Ltd with Agreement State
WEEKMONTHYEAR2012-09-27T05:00:00 [Table view]
[ENS list for Gunderson Clinic, Ltd]

Retrieved from "https://kanterella.com/w/index.php?title=ENS_46574&oldid=87875"

ENS Notification