ENS 52629: Difference between revisions
Jump to navigation
Jump to search
StriderTol (talk | contribs) (Created page by program invented by Mark Hawes) |
StriderTol (talk | contribs) (Created page by program invented by StriderTol) |
||
| Line 16: | Line 16: | ||
| event date = 12/09/2016 CDT | | event date = 12/09/2016 CDT | ||
| last update date = 03/22/2017 | | last update date = 03/22/2017 | ||
| title = Agreement State Report - Total Dose Less | | title = Agreement State Report - Total Dose Less than 80 Percent of Prescribed Dose | ||
| event text = The following report was received from the Wisconsin Department of Health Services via email: | | event text = The following report was received from the Wisconsin Department of Health Services via email: | ||
On March 22, 2017, the [Wisconsin Department of Health Services] received a telephone call and email from the licensee's medical physicist that a medical event occurred on December 9, 2016, 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% 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 114 Gy. The licensee uses D90 (dose delivered to 90% of the clinical target volume) less than 80% for determining medical events. Using the licensee's dose based criteria; the dose received by the prostate was 78% of the intended dose. The underdose was identified during the post-implant computed tomography scan on January 9, 2017 and subsequent dosimetric analysis on January 27, 2017. The licensee's radiation oncologist informed the physicist that supplemental radiation will not be administered and that it is a reportable event on March 22, 2017. Corrective actions are being reviewed by the licensee's staff. DHS [Department of Health Services] inspectors will investigate this medical event. | On March 22, 2017, the [Wisconsin Department of Health Services] received a telephone call and email from the licensee's medical physicist that a medical event occurred on December 9, 2016, 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% 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 114 Gy. The licensee uses D90 (dose delivered to 90% of the clinical target volume) less than 80% for determining medical events. Using the licensee's dose based criteria; the dose received by the prostate was 78% of the intended dose. The underdose was identified during the post-implant computed tomography scan on January 9, 2017 and subsequent dosimetric analysis on January 27, 2017. The licensee's radiation oncologist informed the physicist that supplemental radiation will not be administered and that it is a reportable event on March 22, 2017. Corrective actions are being reviewed by the licensee's staff. DHS [Department of Health Services] inspectors will investigate this medical event. | ||
Latest revision as of 20:43, 1 March 2018
| 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:+2485.3 h103.554 days <br />14.793 weeks <br />3.404 months <br />) | |
| Opened: | David Reindl 17:18 Mar 22, 2017 |
| NRC Officer: | Dong Park |
| Last Updated: | Mar 22, 2017 |
| 52629 - NRC Website | |