ENS 52629

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v t e ENS Event
05:00 Dec 9, 2016
Title	Agreement State Report - Total Dose Less than 80 Percent of Prescribed Dose
Event Description	The following report was received from the Wisconsin Department of Health Services via email: On March 22, 2017, the [Wisconsin Department of Health Services] received a telephone call and email from the licensee's medical physicist that a medical event occurred on December 9, 2016, involving a permanent implant of I-125 seeds for a prostate manual brachytherapy procedure where the total dose delivered differs from the prescribed dose by 20% or more. This is a medical event as described in DHS 157.72(1)(a)1.a. The prescribed dose was 145 Gy; the dose delivered was 114 Gy. The licensee uses D90 (dose delivered to 90% of the clinical target volume) less than 80% for determining medical events. Using the licensee's dose based criteria; the dose received by the prostate was 78% of the intended dose. The underdose was identified during the post-implant computed tomography scan on January 9, 2017 and subsequent dosimetric analysis on January 27, 2017. The licensee's radiation oncologist informed the physicist that supplemental radiation will not be administered and that it is a reportable event on March 22, 2017. Corrective actions are being reviewed by the licensee's staff. DHS [Department of Health Services] inspectors will investigate this medical event. Wisconsin Event ID No.: WI-170005 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.

ENS 52629 +/-
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:+2485.3 h103.554 days <br />14.793 weeks <br />3.404 months <br />)
Opened:	David Reindl 17:18 Mar 22, 2017
NRC Officer:	Dong Park
Last Updated:	Mar 22, 2017
52629 - NRC Website
v • d • e

v t e Emergency Notification System
Aspirus-Wausau Hospital with Agreement State
WEEKMONTHYEAR2023-11-08T06:00:00 [Table view]
[ENS list for Aspirus-Wausau Hospital]

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