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. |
| 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 | |
Gunderson Clinic, Ltd with Agreement State | |
WEEKMONTHYEARENS 483552012-09-27T05:00:00027 September 2012 05:00:00
[Table view]Agreement State Agreement State Report - Theraseed Model 200 Seed Cartridges Failed to Function ENS 465742011-01-26T06:00:00026 January 2011 06:00:00 Agreement State Agreement State Report - Prostate Brachytherapy Medical Underdose 2012-09-27T05:00:00 | |