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 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. |
| 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: | Oct 11, 2017 |
| 53009 - NRC Website | |
Aspirus-Wausau Hospital with Agreement State | |
WEEKMONTHYEARENS 568542023-11-08T06:00:0008 November 2023 06:00:00
[Table view]Agreement State Agreement State - Door Interlock Failure ENS 531682018-01-05T06:00:0005 January 2018 06:00:00 Agreement State Agreement State Report - Delivered Dosage Different from Prescribed ENS 531482018-01-04T06:00:0004 January 2018 06:00:00 Agreement State Agreement State Report - Delivered Dosage Different from Prescribed ENS 530092017-08-11T05:00:00011 August 2017 05:00:00 Agreement State Agreement State Report - Medical Underdose ENS 526292016-12-09T05:00:0009 December 2016 05:00:00 Agreement State Agreement State Report - Total Dose Less than 80 Percent of Prescribed Dose ENS 520352016-06-17T05:00:00017 June 2016 05:00:00 Agreement State Agreement State Report - Contamination of Brachytherapy Patient 2023-11-08T06:00:00 | |