ENS Event | |
|---|---|
05:00 Jul 31, 2025 | |
| Title | Medical Event |
| Event Description | The following information was provided by the Wisconsin Department of Health Services (the Department) via email:
On July 31, 2025, the licensee was treating the third of five fractions for a gynecological cylinder HDR (high dose rate) treatment. The authorized user placed the cylinder prior to treatment and confirmed that they believed it was snug and fully inserted. The licensee also utilized briefs with Velcro straps to hold the cylinder in place. Following the completion of the treatment, the authorized user identified that the cylinder was no longer snug, and that it had shifted by up to one centimeter. It is unclear whether the shift happened during or after treatment. The prescribed dose was 6 Gy for the fraction. The licensee performed a dose reconstruction and determined that if the cylinder had shifted immediately, the cervix would have only received 2.6 Gy (44 percent) of the dose. The licensee believes that the shift would not have resulted in a dose to other organs above regulatory limits, and that the completion of the remaining fractions will result in the desired clinical outcome. The authorized user notified the patient immediately. The Department will perform an investigation. Wisconsin Item Number: WI250007 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:+9.78 h0.408 days <br />0.0582 weeks <br />0.0134 months <br />) | |
| Opened: | Kyle Walton 14:47 Jul 31, 2025 |
| NRC Officer: | Ossy Font |
| Last Updated: | Jul 31, 2025 |
| 57842 - NRC Website | |
Aspirus Wausau Hospital with Agreement State | |
WEEKMONTHYEARENS 578422025-07-31T05:00:00031 July 2025 05:00:00
[Table view]Agreement State Medical Event 2025-07-31T05:00:00 | |