ENS 53148: Difference between revisions
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| event date = 01/04/2018 CST | | event date = 01/04/2018 CST | ||
| last update date = 01/05/2018 | | last update date = 01/05/2018 | ||
| title = Agreement State Report - Delivered Dosage Different | | title = Agreement State Report - Delivered Dosage Different from Prescribed | ||
| event text = The following was received from the State of Wisconsin: | | event text = The following was received from the State of Wisconsin: | ||
On January 4, 2018, the Department [Wisconsin Radiation Protection Section] received a telephone call and email from the licensee's medical physicist that a medical event of a prostate brachytherapy procedure was identified on January 4, 2018. The total dose delivered differs from the prescribed dose by 20% or more. This is a medical event as described in DHS [Department of Health Services] 157.72(1)(a)1.a. The prescribed dose was 145 Gy; the dose delivered was 105 Gy. The licensee uses D90 (dose delivered to 90% of the clinical target volume) < 80% for determining medical events. Using the licensee's dose based criteria; the dose received by the prostate was 75% of the intended dose. The post-implant computed tomography scan occurred on December 6, 2017. The subsequent dosimetric analysis was on January 3, 2018. The department will perform a site investigation to determine the root cause of this medical event. | On January 4, 2018, the Department [Wisconsin Radiation Protection Section] received a telephone call and email from the licensee's medical physicist that a medical event of a prostate brachytherapy procedure was identified on January 4, 2018. The total dose delivered differs from the prescribed dose by 20% or more. This is a medical event as described in DHS [Department of Health Services] 157.72(1)(a)1.a. The prescribed dose was 145 Gy; the dose delivered was 105 Gy. The licensee uses D90 (dose delivered to 90% of the clinical target volume) < 80% for determining medical events. Using the licensee's dose based criteria; the dose received by the prostate was 75% of the intended dose. The post-implant computed tomography scan occurred on December 6, 2017. The subsequent dosimetric analysis was on January 3, 2018. The department will perform a site investigation to determine the root cause of this medical event. | ||
Latest revision as of 20:41, 1 March 2018
| Where | |
|---|---|
| Aspirus-Wausau Hospital Wausau, Illinois (NRC Region 3) | |
| License number: | 073-1342-01 |
| Organization: | Wisconsin Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+26.5 h1.104 days <br />0.158 weeks <br />0.0363 months <br />) | |
| Opened: | Krista Kuhlman 08:30 Jan 5, 2018 |
| NRC Officer: | Andrew Waugh |
| Last Updated: | Jan 5, 2018 |
| 53148 - NRC Website | |