ENS Event | |
|---|---|
06:00 Jan 4, 2018 | |
| Title | Agreement State Report - Delivered Dosage Different From Prescribed |
| Event Description | 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. DHS inspectors will investigate this medical event. Wisconsin Event: WI180001 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, 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 | |
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 | |