ENS 53009
ENS Event | |
|---|---|
05:00 Aug 11, 2017 | |
| Title | Agreement State Report - Medical Underdose |
| Event Description | The following report was received via e-mail:
On October 10, 2017, the Department [Wisconsin Department of Health Services] received a telephone call and email from the licensee's medical physicist that a medical event occurred on August 11, 2017, involving a permanent implant of I-125 seeds for a prostate manual brachytherapy procedure where the total dose delivered differs from the prescribed dose by 20 percent or more. This is a medical event as described in DHS 157.72(1)(a)1.a. The prescribed dose was 145 Gy; the dose delivered was 90 Gy. The licensee uses D90 (dose delivered to 90 percent of the clinical target volume) < 80 percent of prescribed, for determining medical events. Using the licensee's dose based criteria; the dose received by the prostate was 62 percent of the intended dose. The underdose was identified during the post-implant computerized tomography scan on September 11, 2017 and subsequent dosimetric analysis on October 10, 2017. DHS [Wisconsin Department of Health Services] inspectors will investigate this medical event. Wisconsin Event Report: WI170016
The following update was received from the Wisconsin Department of Health Services (DHS) by email: During the ongoing investigations of other medical events reported to the Wisconsin Department of Health Services in 2017, licensee reviewed historic permanent implants of I-125 seeds for prostate manual brachytherapy. The licensee recently identified two additional implants that resulted in a D90 dose to the prostate that was greater than 130 percent of the prescribed dose. The licensee noted that there were no adverse outcomes to the patients. The first implant occurred on August 28, 2015. The prescribed dose to 90 percent of the prostate (D90) was 145 Gy and the D90 delivered was 192 Gy. The second implant occurred on June 17, 2016. The prescribed dose to 90 percent of the prostate (D90) was 145 Gy and the D90 delivered was 189 Gy. DHS is reviewing the circumstances surrounding these two implants as part of the investigation into the previously reported medical events. Notified R3DO (Stone) and NMSS Events. 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-Wausau Hospital Wausau, Wisconsin (NRC Region 3) | |
| License number: | 073-1342-01 |
| Organization: | Wisconsin Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+1472.97 h61.374 days <br />8.768 weeks <br />2.018 months <br />) | |
| Opened: | Joseph Ross 13:58 Oct 11, 2017 |
| NRC Officer: | Mark Abramovitz |
| Last Updated: | Apr 26, 2018 |
| 53009 - NRC Website | |
Aspirus-Wausau Hospital with Agreement State | |
WEEKMONTHYEARENS 568542023-11-08T06:00:0008 November 2023 06:00:00
[Table view]Agreement State Agreement State - Door Interlock Failure ENS 531682018-01-05T06:00:0005 January 2018 06:00:00 Agreement State Agreement State Report - Delivered Dosage Different from Prescribed ENS 531482018-01-04T06:00:0004 January 2018 06:00:00 Agreement State Agreement State Report - Delivered Dosage Different from Prescribed ENS 530092017-08-11T05:00:00011 August 2017 05:00:00 Agreement State Agreement State Report - Medical Underdose ENS 526292016-12-09T05:00:0009 December 2016 05:00:00 Agreement State Agreement State Report - Total Dose Less than 80 Percent of Prescribed Dose ENS 520352016-06-17T05:00:00017 June 2016 05:00:00 Agreement State Agreement State Report - Contamination of Brachytherapy Patient 2023-11-08T06:00:00 | |