ENS 53009: Difference between revisions

v t e ENS Event
05:00 Aug 11, 2017
Title	Agreement State Report - Medical Underdose
Event Description	The following report was received via e-mail: On October 10, 2017, the Department [Wisconsin Department of Health Services] received a telephone call and email from the licensee's medical physicist that a medical event occurred on August 11, 2017, 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 percent or more. This is a medical event as described in DHS 157.72(1)(a)1.a. The prescribed dose was 145 Gy; the dose delivered was 90 Gy. The licensee uses D90 (dose delivered to 90 percent of the clinical target volume) < 80 percent of prescribed, for determining medical events. Using the licensee's dose based criteria; the dose received by the prostate was 62 percent of the intended dose. The underdose was identified during the post-implant computerized tomography scan on September 11, 2017 and subsequent dosimetric analysis on October 10, 2017. DHS [Wisconsin Department of Health Services] inspectors will investigate this medical event. Wisconsin Event Report: WI170016 * * UPDATE ON 4/26/18 AT 1238 EDT FROM JOSEPH ROSS TO BETHANY CECERE * * * The following update was received from the Wisconsin Department of Health Services (DHS) by email: During the ongoing investigations of other medical events reported to the Wisconsin Department of Health Services in 2017, licensee reviewed historic permanent implants of I-125 seeds for prostate manual brachytherapy. The licensee recently identified two additional implants that resulted in a D90 dose to the prostate that was greater than 130 percent of the prescribed dose. The licensee noted that there were no adverse outcomes to the patients. The first implant occurred on August 28, 2015. The prescribed dose to 90 percent of the prostate (D90) was 145 Gy and the D90 delivered was 192 Gy. The second implant occurred on June 17, 2016. The prescribed dose to 90 percent of the prostate (D90) was 145 Gy and the D90 delivered was 189 Gy. DHS is reviewing the circumstances surrounding these two implants as part of the investigation into the previously reported medical events. Notified R3DO (Stone) and NMSS Events. 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 53009 +/-
Where
Aspirus-Wausau Hospital Wausau, Wisconsin (NRC Region 3)
License number:	073-1342-01
Organization:	Wisconsin Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+1472.97 h61.374 days <br />8.768 weeks <br />2.018 months <br />)
Opened:	Joseph Ross 13:58 Oct 11, 2017
NRC Officer:	Mark Abramovitz
Last Updated:	Apr 26, 2018
53009 - NRC Website
v • d • e

v t e Emergency Notification System
Aspirus-Wausau Hospital with Agreement State
WEEKMONTHYEAR2023-11-08T06:00:00 [Table view]
[ENS list for Aspirus-Wausau Hospital]

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 Notified R3DO (Stone) and NMSS Events.
 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.
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+| URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2018/20180604en.html#en53009
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ENS 53009: Difference between revisions

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ENS 53009: Difference between revisions

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