ENS Event | |
|---|---|
05:00 Jul 24, 2012 | |
| Title | Agreement State Report- Underdose During a Brachytherapy Treatment |
| Event Description | The following information was received by email:
Wisconsin Department of Health Services (DHS) received notification via voicemail from the licensee on July 23, 2012 regarding the discovery of a brachytherapy medical event that occurred on July 17, 2007. The medical event involved a procedure during which the administered dose differed from the prescribed dose by more than 20% (underdose) for permanent prostate implants using Cs-131 seeds. The prescribed dose was 115 Gy. The delivered dose was 60 Gy. The medical event was identified by DHS inspectors during a recent routine inspection, at which time the inspectors also determined that the licensee had not conducted adequate review of their prostate brachytherapy cases against their medical event criteria. Per the licensee's procedures, a post-implant CT is performed the same day as the procedure and analyzed within two working days after. If the post-implant analysis reveals an underdose, which occurred in this situation, additional seeds are implanted and another post-implant CT/analysis process follows. The licensee is currently reviewing additional cases dating back to 2003 for medical events against the revised medical event criteria submitted to DHS on June 22, 2012. DHS is investigating the event and is currently in the process of communicating with the licensee regarding decisions on patient notifications. A special inspection team will be sent following the licensee's review. Wisconsin Event: WI 120009 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 | |
|---|---|
| Watertown Memorial Hospital Watertown, Wisconsin (NRC Region 3) | |
| License number: | 055-1335-01 |
| Organization: | Wisconsin Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+9.38 h0.391 days <br />0.0558 weeks <br />0.0128 months <br />) | |
| Opened: | Royston Ngwayah 14:23 Jul 24, 2012 |
| NRC Officer: | Vince Klco |
| Last Updated: | Jul 24, 2012 |
| 48128 - NRC Website | |
Watertown Memorial Hospital with Agreement State | |
WEEKMONTHYEARENS 481282012-07-24T05:00:00024 July 2012 05:00:00
[Table view]Agreement State Agreement State Report- Underdose During a Brachytherapy Treatment 2012-07-24T05:00:00 | |