ENS Event | |
|---|---|
05:00 Apr 4, 2007 | |
| Title | Improper Applicator Length Leads To Wrong Dose |
| Event Description | St. Vincent Hospital, (Green Bay, Wisconsin) notified [the state of Wisconsin] of a medical event by telephone, on April 5, 2007. The medical event occurred on April 4, 2007 and involved an HDR unit. Initial information indicated an incorrect length of catheter was used during the treatment. A [state] inspector was dispatched to the facility on April 6, 2007.
On April 4, 2007, a patient was scheduled for a single-fraction interstitial treatment using a Varian Vari-Source HDR unit containing 6.24 Curies of Iridium-192. The patient was to receive 900 centigray to the vagina. An incorrect applicator length (100 cm) was input into the treatment plan. The actual applicator length was 120 centimeters. The source is believed not to have entered the patient's body during treatment. The authorized user and the patient were notified, and the patient will return for retreatment on April 12. The licensee is performing their own investigation into the event, including a reenactment of the event. 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 Green Bay, Wisconsin (NRC Region 3) | |
| Organization: | Wisconsin Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+55.45 h2.31 days <br />0.33 weeks <br />0.076 months <br />) | |
| Opened: | Paul Schmidt 12:27 Apr 6, 2007 |
| NRC Officer: | Pete Snyder |
| Last Updated: | Apr 6, 2007 |
| 43288 - 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 | |