ENS 46975

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v t e ENS Event
05:00 Jun 15, 2011
Title	Agreement State Report - Two I-125 Incidents Involving Total Dose Less than Prescribed Dose
Event Description	The State of Wisconsin sent the following report via email: On June 15, 2011, the licensee's Radiation Safety Officer reported the identification of two medical events that were discovered, involving permanent implants of I-125 for prostate brachytherapy where the total dose delivered differs from the prescribed dose by 20% or more. During a routine inspection conducted on March 8, 2011, DHS (Department of Health Services) inspectors determined that the licensee was not reviewing prostate brachytherapy cases against the medical event criteria and identified numerous potential medical events. A Confirmatory Action Letter was sent on April 6, 2011 which required the licensee to have all of their manual brachytherapy prostate implants reviewed by an outside radiation oncologist. Upon completion of the external review of the licensee's manual brachytherapy program for prostate implants, the licensee identified the following underdoses to the prostate (using D90<80% and D90>120% as medical event criteria): December 12, 2005: Prescribed dose 108 Gy. Prostate D90 was 67.16%. July 26, 2007: Prescribed dose 144 Gy. Prostate D90 was 74.09%. The licensee RSO stated that they will not be notifying the patients involved. DHS will send a special inspection team following the receipt of the licensee's 15 day written report. Wisconsin Event Report ID No.: WI10007 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 46975 +/-
Where
St. Mary'S Hospital - Rhinelander Rhinelander, Wisconsin (NRC Region 3)
License number:	085-1296-01
Organization:	Wisconsin Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+151.62 h6.318 days <br />0.902 weeks <br />0.208 months <br />)
Opened:	Cheryl K. Rogers 12:37 Jun 21, 2011
NRC Officer:	Steve Sandin
Last Updated:	Jun 21, 2011
46975 - NRC Website
v • d • e

v t e Emergency Notification System
St. Mary'S Hospital - Rhinelander with Agreement State
WEEKMONTHYEAR2011-06-15T05:00:00 [Table view]
[ENS list for St. Mary'S Hospital - Rhinelander]

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