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| Entered date | Event description | |
|---|---|---|
| ENS 43288 | 6 April 2007 12:27:00 | St. Vincent Hospital, (Green Bay, Wisconsin) notified (the state of Wisconsin) of a medical event by telephone, on April 5, 2007. The medical event occurred on April 4, 2007 and involved an HDR unit. Initial information indicated an incorrect length of catheter was used during the treatment. A (state) inspector was dispatched to the facility on April 6, 2007. On April 4, 2007, a patient was scheduled for a single-fraction interstitial treatment using a Varian Vari-Source HDR unit containing 6.24 Curies of Iridium-192. The patient was to receive 900 centigray to the vagina. An incorrect applicator length (100 cm) was input into the treatment plan. The actual applicator length was 120 centimeters. The source is believed not to have entered the patient's body during treatment. The authorized user and the patient were notified, and the patient will return for retreatment on April 12. The licensee is performing their own investigation into the event, including a reenactment of the event. 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 41576 | 8 April 2005 14:07:00 | The licensee provided the following information via facsimile (licensee text in quotes): On Friday, April 8, 2005 at approximately 8:30 a.m., the Wisconsin Radiation Protection Section (RPS) received notification from the University of Wisconsin, Madison, WI (license number 25-1323-01) of a potential medical event involving a therapeutic radiation dose from a Yittrium-90 Zevelin treatment in which the delivered dose may have differed from the prescribed dose by more than 0.5 Sv (50 rem) and by 20% or more of the prescribed dose. (HFS 157.72 (1) (a) 1.) On Tuesday, April 5, 2005, a physician at the University of Wisconsin Hospital and Clinics, Madison, WI administered a 48 mCi dose of Y-90 Zevalin to a patient. Based upon patient weight and platelet count, the intended dose should have been 28 mCi. The dose was dispensed as a unit dose by a nuclear pharmacy and administered as received. There is no indication of a written directive. The error was not discovered until Thursday, April 7 during a licensee review of records. The licensee is investigating the incident. The ordering physician has been notified HFS 157.72 (1) (a) 1. requires a licensee to report an event in which the administration of radioactive material or resulting radiation results in 'A dose that differs from the prescribed dose by more than 0.05 Sv (5 rem), 0.5 Sv (50 Rem) to an organ or tissue or 0.5 Sv (50 rem) shallow dose equivalent to the skin and the total dose delivered differs from the prescribed dose by 20% or more'. DHFS, RPS staff plan to investigate. |
| ENS 41420 | 18 February 2005 17:04:00 | 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 |
| ENS 41015 | 3 September 2004 15:41:00 | On Friday, September 3, 2004 at approximately 1:30 p.m., the Wisconsin Radiation Protection Section (RPS) received a telephone call from the University of Wisconsin - Madison (license number 25-1323-01) informing the section of a lost Ir-192 source that had been inadvertently shipped to the University of Arizona Medical Center, Tucson, AZ. Preliminary Information From the Licensee On Monday, August 30, 2004, the University of Wisconsin - Madison calibration lab had completed calibration of a Standard Imaging, Model 1000+ reentrant well chamber (ion chamber used to determine brachytherapy seed dose) and shipped it back to the chamber owner, the University of Arizona Medical Center. Shortly after arrival, the U.A. Medical Center discovered that the chamber contained a 0.4 mCi (milliCurie) Iridium-192 brachytherapy seed that had been used during calibration. The U.A. Medical Center subsequently notified the U.W. Madison of the incident on Friday, September 3, 2004. The licensee estimates that the dose rate from an unshielded 0.4 mCi Ir-192 seed source would be approximately 0.192 mR/hr at 1 meter. The licensee believes that the chamber shielded the source so the dose rate on the surface of the shipping container was negligible. |