The following was received from the State of
Wisconsin via email:
An email the department received on January 5, 2018 was believed to be an update to the previous notification [EN #53148]. Upon further review by the department, it was discovered that the email pertained to a second medical event identified by the licensee on January 5, 2018. This was a medical event as described in DHS 157.72(1)(a)1.a. The prescribed dose was 145 Gy; the dose delivered was 70 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 48% of the intended dose. The licensee has an additional criterion that the volume of the CTV to which 100% of the prescription dose delivered must be above 80%. The licensee determined only 62% of the volume received the required dose.
The implant was initially performed on November 10, 2017. A post implant CT scan was performed on December 14, 2017. The physician completed the contour for the dosimetrist to run a Post Seed Plan on January 3, 2018. The dosimetrist notified the physicist of a possible medical event on January 5, 2018.
DHS is investigating and will be performing a site visit in regards to this event.
Wisconsin Event Report ID: WI180002
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.