ENS 46949: Difference between revisions
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| event date = 05/15/2011 CDT | | event date = 05/15/2011 CDT | ||
| last update date = 06/10/2011 | | last update date = 06/10/2011 | ||
| title = Agreement State Report - Medical Events Involving Use | | title = Agreement State Report - Medical Events Involving Use of Savi Brachytherapy Applicators | ||
| event text = The following information was provided by the State via facsimile: | | event text = The following information was provided by the State via facsimile: | ||
On June 10, 2011, the licensee's Radiation Safety Officer reported the identification of two medical events involving a HDR [High Dose Rate] Partial Breast Treatment using SAVI applicators. For both patients, treatment was delivered twice a day for five consecutive days in May 2011. It was determined later that the distance as determine by use of a Varian VariSource check ruler was incorrect. The check wire was blocked approximately 4.5 cm from the end of the lumen. The preliminary results from re-planning indicates that in both cases the most distal half of the applicator was under dosed at least 20 percent and the proximal half received approximately 200 percent more dose than what was prescribed. The patients will be notified by the referring physician. The licensee has suspended SAVI treatments until the root cause can be identified. Further updates will be made through NMED. | On June 10, 2011, the licensee's Radiation Safety Officer reported the identification of two medical events involving a HDR [High Dose Rate] Partial Breast Treatment using SAVI applicators. For both patients, treatment was delivered twice a day for five consecutive days in May 2011. It was determined later that the distance as determine by use of a Varian VariSource check ruler was incorrect. The check wire was blocked approximately 4.5 cm from the end of the lumen. The preliminary results from re-planning indicates that in both cases the most distal half of the applicator was under dosed at least 20 percent and the proximal half received approximately 200 percent more dose than what was prescribed. The patients will be notified by the referring physician. The licensee has suspended SAVI treatments until the root cause can be identified. Further updates will be made through NMED. |
Latest revision as of 22:06, 1 March 2018
Where | |
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St. Vincent Hospital Greenbay, Wisconsin (NRC Region 3) | |
License number: | 009-1303-01 |
Organization: | Wisconsin Radiation Protection |
Reporting | |
Agreement State | |
Time - Person (Reporting Time:+636.28 h26.512 days <br />3.787 weeks <br />0.872 months <br />) | |
Opened: | Mark Paulson 17:17 Jun 10, 2011 |
NRC Officer: | Bill Huffman |
Last Updated: | Jun 10, 2011 |
46949 - NRC Website | |