ENS Event | |
|---|---|
06:00 Feb 10, 2023 | |
| Title | Patient Underdose |
| Event Description | The following information was provided by the Wisconsin Radiation Protection Section via email:
On February 10, 2023, the licensee reported a medical event which had occurred the previous day. A patient was being treated with a high dose rate remote after loader unit and the fraction required 17 needles. After the first 15 needles had been treated, the licensee noticed that the patient's needles had been pulled out approximately 2 cm from where they had been placed due to unexpected movement of the patient's bed. The licensee has not yet determined how the patient's bed moved, as the patient was sedated during treatment. Needles 16 and 17 were re-inserted and the dose to those needles was delivered as intended. The authorized user had prescribed 13.5 Gy to the treatment site for this fraction, and the licensee estimates that only 30 percent of the treatment volume received the prescribed dose. The referring physician and the patient's family have been notified. Event Report ID No: WI230001 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 | |
|---|---|
| University Of Wisconsin-Madison Madison, Wisconsin (NRC Region 3) | |
| License number: | 025-1323-01 |
| Organization: | Wisconsin Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+10.55 h0.44 days <br />0.0628 weeks <br />0.0145 months <br />) | |
| Opened: | Megan Shober 16:33 Feb 10, 2023 |
| NRC Officer: | Ian Howard |
| Last Updated: | Feb 10, 2023 |
| 56349 - NRC Website | |
University Of Wisconsin-Madison with Agreement State | |
WEEKMONTHYEARENS 563492023-02-10T06:00:00010 February 2023 06:00:00
[Table view]Agreement State Patient Underdose 2023-02-10T06:00:00 | |