ENS 54210

v t e ENS Event
05:00 Aug 9, 2019
Title	Agreement State Report - Medical Event - Underdose to Patient
Event Description	The following was received from the Wisconsin Radiation Protection Section via email: On 8/9/19, the Department [State of Wisconsin Department of Health Services] was notified by ThedaCare Regional Medical Center - Appleton of a medical event. The administered TheraSphere dosage had a calibration date of 7/28/2019. The licensee intended to use a calibration date of 8/4/2019. The prescribed dose to the patient was 110 Gy. As a result of the difference in calibration dates, the delivered dose was 17.9 Gy. This was approximately 16 percent of the prescribed dose. The Department will perform a follow-up investigation and site visit. The patient will be notified. Wisconsin Event Report ID: WI190009 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 54210 +/-
Where
Thedacare Regional Medical Center - Appleton Appleton, Wisconsin (NRC Region 3)
License number:	087-1014-01
Organization:	Wisconsin Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+9.9 h0.413 days <br />0.0589 weeks <br />0.0136 months <br />)
Opened:	Kyle Walton 14:54 Aug 9, 2019
NRC Officer:	Caty Nolan
Last Updated:	Aug 9, 2019
54210 - NRC Website
v • d • e

v t e Emergency Notification System
Thedacare Regional Medical Center - Appleton with Agreement State
WEEKMONTHYEAR2019-08-09T05:00:00 [Table view]
[ENS list for Thedacare Regional Medical Center - Appleton]

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