ENS 53168

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v t e ENS Event
06:00 Jan 5, 2018
Title	Agreement State Report - Delivered Dosage Different from Prescribed
Event Description	The following was received from the State of Wisconsin via email: An email the department received on January 5, 2018 was believed to be an update to the previous notification [EN #53148]. Upon further review by the department, it was discovered that the email pertained to a second medical event identified by the licensee on January 5, 2018. This was a medical event as described in DHS 157.72(1)(a)1.a. The prescribed dose was 145 Gy; the dose delivered was 70 Gy. The licensee uses D90 (dose delivered to 90% of the clinical target volume) < 80% for determining medical events. Using the licensee's dose based criteria; the dose received by the prostate was 48% of the intended dose. The licensee has an additional criterion that the volume of the CTV to which 100% of the prescription dose delivered must be above 80%. The licensee determined only 62% of the volume received the required dose. The implant was initially performed on November 10, 2017. A post implant CT scan was performed on December 14, 2017. The physician completed the contour for the dosimetrist to run a Post Seed Plan on January 3, 2018. The dosimetrist notified the physicist of a possible medical event on January 5, 2018. DHS is investigating and will be performing a site visit in regards to this event. Wisconsin Event Report ID: WI180002 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 53168 +/-
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:+279.23 h11.635 days <br />1.662 weeks <br />0.382 months <br />)
Opened:	Kyle Walton 21:14 Jan 16, 2018
NRC Officer:	Howie Crouch
Last Updated:	Jan 18, 2018
53168 - 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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ENS Notification