ENS Event | |
|---|---|
05:00 Jul 19, 2012 | |
| Title | Agreement State Report - 15 Prostate Brachytherapy Medical Events |
| Event Description | The following information was received via facsimile:
On July 19, 2012, the licensee reported the identification of 15 medical events that were discovered on July 18, 2012, involving permanent implants of iodine-125 for prostate brachytherapy where the total dose delivered differs from the prescribed dose by 20% or more. During a recent inspection, DHS [Department of Health Services] inspectors determined that the licensee was not reviewing prostate brachytherapy cases against the medical event criteria. The licensee established dose based criteria used by post-operation CT, prostate D90 values <80% or >130% for classifying medical events. The licensee has evaluated all prostate implants performed since 2001. "--Overdose to the prostate (medical event criteria used -D90>130%): 08/20/2009: 137.3% "--Underdose to the prostate (medical event criteria used -D90<80%): 07/15/2005: 79.27% 03/13/2006: 79.17% 03/15/2006: 67.10% 07/26/2006: 72.35% 07/26/2006: 57.06% 02/13/2006: 78.37% 05/14/2009: 78.67% "--Overdose to the rectum (medical event criteria used -V100>2cc): 12/13/2006: 2.42cc 12/19/2007: 2.23cc 03/03/2009: 2.54cc 07/08/2009: 3.32cc 11/19/2009: 2.89cc 05/05/2010: 2.41cc 05/20/2010: 3.92cc DHS inspectors conducted an investigation of these medical events and are awaiting completion of the licensee's review. Wisconsin Event Report ID No.: WI120008 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 | |
|---|---|
| Wheaton Franciscan Healthcare - All Saints Racine, Wisconsin (NRC Region 3) | |
| License number: | 101-1299-01 |
| Organization: | Wisconsin Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+12.1 h0.504 days <br />0.072 weeks <br />0.0166 months <br />) | |
| Opened: | Emily Eggers 17:06 Jul 19, 2012 |
| NRC Officer: | Donald Norwood |
| Last Updated: | Jul 19, 2012 |
| 48118 - NRC Website | |
Wheaton Franciscan Healthcare - All Saints with Agreement State | |
WEEKMONTHYEARENS 481182012-07-19T05:00:00019 July 2012 05:00:00
[Table view]Agreement State Agreement State Report - 15 Prostate Brachytherapy Medical Events ENS 452222009-07-16T05:00:00016 July 2009 05:00:00 Agreement State Agreement State Report - Multiple Equipment Issues Associated with Hdr Brachytherapy Unit 2012-07-19T05:00:00 | |