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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 56082 | 10 August 2022 05:00:00 | Agreement State | Lost Y-90 Microspheres | The following information was received from the Wisconsin Department of Health Services (the Department) via email: On August 31, 2022, the licensee notified the Department that they had lost control of licensed radioactive material. Per the licensee's report, on or about August 10, 2022, four sharps containers with yttrium-90 microsphere waste were inadvertently taken from the licensee's decay-in-storage room and placed in a locked room in the hospital's shipping department for disposal as biohazardous material. On August 15, 2022, the four sharps containers (approximately 60 millicuries of yttrium-90) were picked up by the hospital's biohazardous waste vendor, where they are assumed to have been autoclaved and disposed in a landfill. The licensee became aware of the loss on August 29, 2022. Based on the current activity of the sources (less than 1 millicurie) no attempt will be made to retrieve the material. No members of the public are expected to exceed public dose limits. A Department investigation is ongoing. WI incident no.: WI220020 THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf | ||
| ENS 50823 | 13 February 2015 06:00:00 | Agreement State | Agreement State Report - Gamma Knife Unit Failed to Function as Designed | The following information was received from the State of Wisconsin via email: On Friday, February 13, 2015, the Wisconsin Radiation Protection Section received notice from the Radiation Safety Officer (RSO) of Marshfield Clinic that their Leksell Gamma Knife Perfexion gamma stereotactic radiosurgery unit failed to function as designed. The Gamma Knife unit became stuck open and staff had to manually retract the patient bed and close the shielding doors on the unit. It is not believed that the patient received a dose higher than was planned but it is unknown if it is a medical event at this time. The Wisconsin Radiation Protection Section will conduct an investigation on Monday, February 16, 2015 and provide updates through NMED. WI Event ID: WI150001 | ||
| ENS 46249 | 9 September 2010 05:00:00 | Agreement State | Agreement State Report - Delivered Dose Is Different from the Prescribed Dose | The following information was received by facsimile: On September 14, 2010, the Department (Wisconsin Department of Health Services) received a facsimile from the licensee's Radiation Safety Officer (RSO) that a medical event occurred on September 9, 2010, 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% or more. This is a medical event as described in DHS 157.72(1)(a)1. The prescribed dose was 145 Gy; the dose delivered was 80 Gy. The licensee uses D80 < 80% as their dose based criteria for determining medical events. Using the licensee's dose based criteria of D80 < 80% the dose received by the prostate was 55% of the intended dose. The underdose was identified during the post-implant planning for the procedure. The RSO indicated that the possible cause was the maximum insertion depth was 0.6 cm below the base of the prostate gland and all needles were implanted distal to the base resulting in the area being 'cold'. Possible corrective actions are under review by the licensee's staff and a one month post-implant CT is planned to determine the impact to the patient. (Department) inspectors will investigate this medical event on September 16, 2010. Wisconsin Event Report: WI100015 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 46082 | 9 July 2010 05:00:00 | Agreement State | Agreement State - Brachytherapy Treatment Dose Delivered Differs from Prescribed | The following was received via fax from the State of Wisconsin: On July 8, 2010, the licensee's Radiation Safety Officer (RSO) reported the preliminary identification of six medical events involving permanent implants of I-125 for prostate brachytherapy where the total dose delivered differs from the prescribed dose by 20% or more. During recent routine inspection, DHS (Department of Health Services) inspectors determined that the licensee was not reviewing prostate brachytherapy cases against the medical event criteria. The licensee is currently evaluating all 269 prostate implants performed since August 2003. This review is ongoing and will include an assessment of whether any implants involved doses to an organ or tissue above 0.50 Sv and 50% more than the expected dose. The licensee is in the process of notifying the affected patients and referring physicians. The reported medical events involve two locations of use. One facility identified three under doses (74.8%, 75.2%, and 76.5%) and one overdose (121.4%). The second facility identified one under dose (78.2%) and one overdose (121.0%). DHS inspectors are investigating these medical events and will send a special inspection team following completion of the licensee's review Event Report No.: WI100012 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.
This is an update to Event Notification 46082. On July 20, 2010, the licensee's Radiation Safety Officer reported the identification of three additional medical events involving permanent implants of I-125 for prostate brachytherapy where the doses to all organ or tissue is above 0.50 Sv and 50% more than the expected dose. The licensee increased the cases reviewed to 275 prostate brachytherapy cases against the medical event criteria. The licensee is in the process of notifying the affected patients and referring physicians. The three additional medical events were overdoses to the urethra (159.7%, 161.3% and 151.6%). DHS inspectors are investigating these medical events and will send a special inspection team. Notified R3DO (Stone) and FSME (Ries). | ||
| ENS 41420 | 16 February 2005 06:00:00 | Agreement State | Agreement State Medical Event | The following information was provided by the State of Wisconsin via facsimile: On Thursday, February 17, 2005 at approximately 3:45p.m. (CST), the Wisconsin Radiation Protection Section (RPS) received a telephone call from the Marshfield Clinic, Marshfield, WI (license number 141-01162-001) informing the section of a medical event involving a therapeutic radiation dose from a gamma knife exposing a site outside the intended treatment volume to a level greater than 50% of the expected dose. (HFS 157.72 (1) (a) 3.) Preliminary Information From the Licensee: On Wednesday, February 16, 2005, the Marshfield Clinic had scheduled a therapeutic radiation treatment of 18 Gray (1800 Rads) using a gamma knife. During the process of manually programming the positioning system, the y and z coordinates were transposed. The error was not noticed during a double check of the treatment coordinates. As a result, a site outside the intended treatment volume received an estimated dose of 5.06 Gray (506 Rads) instead of the originally estimated 0.4 Gray (40 Rads). The volume of the unintended treatment site was 0.7 cubic centimeters. The treatment duration was 2.42 minutes. The prescribed dose of 18 Gray was delivered and the patient treatment was completed. The attending neurosurgeon and radiation oncologist believe there will be no medical consequences to the patient from the unintended exposure. The referring physician has been notified. (State of Wisconsin) is reporting this event under: HFS 157.72 (1) (a) 3. requires a licensee to report an event where there is 'A dose to an organ outside the intended treatment volume that exceeds the expected dose to that organ by 0.5 Sv (50 Rem) where the excess dose is greater than 50% of the expected dose to that organ. . . ' DHFS, RPS staff have been dispatched on Friday, February 18, 2005 to investigate. Wisconsin Incident No: 20 |