ENS Event | |
|---|---|
17:00 Sep 7, 2011 | |
| Title | Agreement State Report - Medical Event Involving an Underdosage |
| Event Description | Wisconsin Department of Health Services (DHS) received notification by phone call from the licensee on September 8, 2011 about a medical event involving I-125 permanent prostate seed implants. During a standard review conducted September 7, 2011 of a post seed implant report the Authorized Medical Physicist determined that the dose delivered differed from the prescribed dose by 20% or more. Specifically it was found that only 76% (110 Gy) of the prescribed dose was delivered to 90% of the CTV for an implant completed on July 22, 2011. The licensee had established the dose based criteria that by post-operation CT, prostate D90 values are < 80% or >130% for classifying medical events. The licensee has notified the Authorized User, referring physician and will notify the patient during a scheduled examine the week of September 11, 2011. There is no expected immediate harm to the patient and the Authorized User and referring physician will discuss with the patient to determine if supplemental radiation (implant or external beam) will be done. DHS conducted an investigating of this medical event on September 9, 2011 by sending a special inspection team. The preliminarily conclusion after reviewing the licensee's procedures and discussion with the Authorized User and Authorized Medical Physicist is that the under dose was directly caused by edema of the prostate, i.e. post implant procedure swelling.
Wisconsin Event Number: WI110014 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 | |
|---|---|
| Aspirus Regional Cancer Center Wasau, Wisconsin (NRC Region 3) | |
| License number: | 073-1342-01 |
| Organization: | Wisconsin Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+47.43 h1.976 days <br />0.282 weeks <br />0.065 months <br />) | |
| Opened: | Mark Paulson 16:26 Sep 9, 2011 |
| NRC Officer: | Vince Klco |
| Last Updated: | Sep 9, 2011 |
| 47254 - NRC Website | |
Aspirus Regional Cancer Center with Agreement State | |
WEEKMONTHYEARENS 472542011-09-07T17:00:0007 September 2011 17:00:00
[Table view]Agreement State Agreement State Report - Medical Event Involving an Underdosage 2011-09-07T17:00:00 | |