ENS Event | |
|---|---|
05:00 Dec 9, 2016 | |
| Title | Agreement State Report - Total Dose Less than 80 Percent of Prescribed Dose |
| Event Description | 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. Wisconsin Event ID No.: WI-170005 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:+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 | |
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 | |