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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 46975 | 15 June 2011 05:00:00 | Agreement State | Agreement State Report - Two I-125 Incidents Involving Total Dose Less than Prescribed Dose | The State of Wisconsin sent the following report via email: On June 15, 2011, the licensee's Radiation Safety Officer reported the identification of two medical events that were discovered, involving permanent implants of I-125 for prostate brachytherapy where the total dose delivered differs from the prescribed dose by 20% or more. During a routine inspection conducted on March 8, 2011, DHS (Department of Health Services) inspectors determined that the licensee was not reviewing prostate brachytherapy cases against the medical event criteria and identified numerous potential medical events. A Confirmatory Action Letter was sent on April 6, 2011 which required the licensee to have all of their manual brachytherapy prostate implants reviewed by an outside radiation oncologist. Upon completion of the external review of the licensee's manual brachytherapy program for prostate implants, the licensee identified the following underdoses to the prostate (using D90<80% and D90>120% as medical event criteria): December 12, 2005: Prescribed dose 108 Gy. Prostate D90 was 67.16%. July 26, 2007: Prescribed dose 144 Gy. Prostate D90 was 74.09%. The licensee RSO stated that they will not be notifying the patients involved. DHS will send a special inspection team following the receipt of the licensee's 15 day written report. Wisconsin Event Report ID No.: WI10007 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. |