ENS Event | |
|---|---|
05:00 May 15, 2011 | |
| Title | Agreement State Report - Medical Events Involving Use of Savi Brachytherapy Applicators |
| Event Description | The following information was provided by the State via facsimile:
On June 10, 2011, the licensee's Radiation Safety Officer reported the identification of two medical events involving a HDR [High Dose Rate] Partial Breast Treatment using SAVI applicators. For both patients, treatment was delivered twice a day for five consecutive days in May 2011. It was determined later that the distance as determine by use of a Varian VariSource check ruler was incorrect. The check wire was blocked approximately 4.5 cm from the end of the lumen. The preliminary results from re-planning indicates that in both cases the most distal half of the applicator was under dosed at least 20 percent and the proximal half received approximately 200 percent more dose than what was prescribed. The patients will be notified by the referring physician. The licensee has suspended SAVI treatments until the root cause can be identified. Further updates will be made through NMED. The State of Wisconsin Department of Health Services will conduct a special inspection at the licensee's location. Wisconsin Report No: WI 110006 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 | |
|---|---|
| St. Vincent Hospital Greenbay, Wisconsin (NRC Region 3) | |
| License number: | 009-1303-01 |
| Organization: | Wisconsin Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+636.28 h26.512 days <br />3.787 weeks <br />0.872 months <br />) | |
| Opened: | Mark Paulson 17:17 Jun 10, 2011 |
| NRC Officer: | Bill Huffman |
| Last Updated: | Jun 10, 2011 |
| 46949 - NRC Website | |
St. Vincent Hospital with Agreement State | |
WEEKMONTHYEARENS 469492011-05-15T05:00:00015 May 2011 05:00:00
[Table view]Agreement State Agreement State Report - Medical Events Involving Use of Savi Brachytherapy Applicators ENS 465292011-01-10T06:00:00010 January 2011 06:00:00 Agreement State Agreement State Report - Prostate Brachytherapy Misdosing ENS 432882007-04-04T05:00:0004 April 2007 05:00:00 Agreement State Improper Applicator Length Leads to Wrong Dose 2011-05-15T05:00:00 | |