ENS 46949

v t e ENS Event
05:00 May 15, 2011
Title	Agreement State Report - Medical Events Involving Use of Savi Brachytherapy Applicators
Event Description	The following information was provided by the State via facsimile: On June 10, 2011, the licensee's Radiation Safety Officer reported the identification of two medical events involving a HDR [High Dose Rate] Partial Breast Treatment using SAVI applicators. For both patients, treatment was delivered twice a day for five consecutive days in May 2011. It was determined later that the distance as determine by use of a Varian VariSource check ruler was incorrect. The check wire was blocked approximately 4.5 cm from the end of the lumen. The preliminary results from re-planning indicates that in both cases the most distal half of the applicator was under dosed at least 20 percent and the proximal half received approximately 200 percent more dose than what was prescribed. The patients will be notified by the referring physician. The licensee has suspended SAVI treatments until the root cause can be identified. Further updates will be made through NMED. The State of Wisconsin Department of Health Services will conduct a special inspection at the licensee's location. Wisconsin Report No: WI 110006 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 46949 +/-
Where
St. Vincent Hospital Greenbay, Wisconsin (NRC Region 3)
License number:	009-1303-01
Organization:	Wisconsin Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+636.28 h26.512 days <br />3.787 weeks <br />0.872 months <br />)
Opened:	Mark Paulson 17:17 Jun 10, 2011
NRC Officer:	Bill Huffman
Last Updated:	Jun 10, 2011
46949 - NRC Website
v • d • e

v t e Emergency Notification System
St. Vincent Hospital with Agreement State
WEEKMONTHYEAR2011-05-15T05:00:00 [Table view]
[ENS list for St. Vincent Hospital]

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