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The following information was received via … The following information was received via facsimile:</br>On July 19, 2012, the licensee reported the identification of 15 medical events that were discovered on July 18, 2012, involving permanent implants of iodine-125 for prostate brachytherapy where the total dose delivered differs from the prescribed dose by 20% or more. During a recent inspection, DHS (Department of Health Services) inspectors determined that the licensee was not reviewing prostate brachytherapy cases against the medical event criteria. The licensee established dose based criteria used by post-operation CT, prostate D90 values <80% or >130% for classifying medical events. The licensee has evaluated all prostate implants performed since 2001.</br> "--Overdose to the prostate (medical event criteria used -D90>130%):</br> 08/20/2009: 137.3%</br> "--Underdose to the prostate (medical event criteria used -D90<80%):</br> 07/15/2005: 79.27%</br> 03/13/2006: 79.17%</br> 03/15/2006: 67.10%</br> 07/26/2006: 72.35%</br> 07/26/2006: 57.06%</br> 02/13/2006: 78.37%</br> 05/14/2009: 78.67%</br> "--Overdose to the rectum (medical event criteria used -V100>2cc):</br> 12/13/2006: 2.42cc</br> 12/19/2007: 2.23cc</br> 03/03/2009: 2.54cc</br> 07/08/2009: 3.32cc</br> 11/19/2009: 2.89cc</br> 05/05/2010: 2.41cc</br> 05/20/2010: 3.92cc</br>DHS inspectors conducted an investigation of these medical events and are awaiting completion of the licensee's review.</br>Wisconsin Event Report ID No.: WI120008</br>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.. It does not necessarily result in harm to the patient. +
05:00:00, 19 July 2012 +
48,118 +
17:06:00, 19 July 2012 +
05:00:00, 19 July 2012 +
The following information was received via … The following information was received via facsimile:</br>On July 19, 2012, the licensee reported the identification of 15 medical events that were discovered on July 18, 2012, involving permanent implants of iodine-125 for prostate brachytherapy where the total dose delivered differs from the prescribed dose by 20% or more. During a recent inspection, DHS (Department of Health Services) inspectors determined that the licensee was not reviewing prostate brachytherapy cases against the medical event criteria. The licensee established dose based criteria used by post-operation CT, prostate D90 values <80% or >130% for classifying medical events. The licensee has evaluated all prostate implants performed since 2001.</br> "--Overdose to the prostate (medical event criteria used -D90>130%):</br> 08/20/2009: 137.3%</br> "--Underdose to the prostate (medical event criteria used -D90<80%):</br> 07/15/2005: 79.27%</br> 03/13/2006: 79.17%</br> 03/15/2006: 67.10%</br> 07/26/2006: 72.35%</br> 07/26/2006: 57.06%</br> 02/13/2006: 78.37%</br> 05/14/2009: 78.67%</br> "--Overdose to the rectum (medical event criteria used -V100>2cc):</br> 12/13/2006: 2.42cc</br> 12/19/2007: 2.23cc</br> 03/03/2009: 2.54cc</br> 07/08/2009: 3.32cc</br> 11/19/2009: 2.89cc</br> 05/05/2010: 2.41cc</br> 05/20/2010: 3.92cc</br>DHS inspectors conducted an investigation of these medical events and are awaiting completion of the licensee's review.</br>Wisconsin Event Report ID No.: WI120008</br>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.. It does not necessarily result in harm to the patient. +
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101-1299-01 +
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17:06:00, 19 July 2012 +
0.504 d (12.1 hours, 0.072 weeks, 0.0166 months) +
05:00:00, 19 July 2012 +
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