ENS 53512

v t e ENS Event
05:00 Jul 17, 2018
Title	Agreement State Report - Total Dose Delivered Differed from Prescribed Dose by Greater than 20 Percent
Event Description	The following information was received from the state of Wisconsin via email: On July 17, 2018, the licensee identified a medical event where the total dose delivered differed from the prescribed dose by 20 percent or more. The licensee implanted 83 seeds containing Pd-103 for prostate brachytherapy. The prescribed dose to the prostate was 125 Gy; the dose delivered was 96.25 Gy. The dose received by the prostate (D90) was 77 percent of the intended dose. The patient has been notified. The implant occurred on June 8, 2018, and post-implant dosimetry was completed on July 17, 2018. The department will perform a site investigation to determine the root cause of this medical event. Event Report ID No.: WI180011 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 53512 +/-
Where
Aurora Baycare Medical Center Green Bay, Wisconsin (NRC Region 3)
License number:	009-1017-01
Organization:	Wisconsin Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+12.9 h0.538 days <br />0.0768 weeks <br />0.0177 months <br />)
Opened:	Megan Shober 17:54 Jul 17, 2018
NRC Officer:	Brian Lin
Last Updated:	Jul 17, 2018
53512 - NRC Website
v • d • e

v t e Emergency Notification System
Aurora Baycare Medical Center with Agreement State
WEEKMONTHYEAR2018-07-17T05:00:00 [Table view]
[ENS list for Aurora Baycare Medical Center]

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