Event Notification Report for July 06, 2005
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/05/2005 - 07/06/2005
EVENT NUMBERS
41827
General Information or Other
Event Number: 41827
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: ASPIRUS - WAUSAU HOSPITAL
Region: 3
City: WAUSAU State: WI
County:
License #: 073-1342-01
Agreement: Y
Docket:
NRC Notified By: PAUL J. CALEB
HQ OPS Officer: MIKE RIPLEY
Licensee: ASPIRUS - WAUSAU HOSPITAL
Region: 3
City: WAUSAU State: WI
County:
License #: 073-1342-01
Agreement: Y
Docket:
NRC Notified By: PAUL J. CALEB
HQ OPS Officer: MIKE RIPLEY
Notification Date: 07/08/2005
Notification Time: 15:45 [ET]
Event Date: 07/06/2005
Event Time: 00:00 [CDT]
Last Update Date: 07/08/2005
Notification Time: 15:45 [ET]
Event Date: 07/06/2005
Event Time: 00:00 [CDT]
Last Update Date: 07/08/2005
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
LAURA KOZAK (R3)
GARY JANOSKO (NMSS)
LAURA KOZAK (R3)
GARY JANOSKO (NMSS)
WISCONSIN AGREEMENT STATE REPORT - MEDICAL EVENT
The State provided the following information via email:
"On July 6, 2005, a brachytherapy procedure to treat a bile duct carcinoma using 22 iridium-192 sources totaling 53.9 milliCuries in a ribbon with spacing of 0.5 centimeter between each source was performed. The ribbon was routed through the nasal gastric system to the treatment site (bile duct). A radiograph was taken of the source placement in the bile duct before releasing the patient to a hospital room. The radiograph verified the sources to be in the prescribed location.
"On July 7, 2005, a verification image was taken at 0850 and found that the radioactive sources had moved approximately 5 centimeters toward the gastrointestinal tract. The location of the sources was outside of the intended site. An attempt to reposition the source ribbon by the authorized user was unsuccessful. The authorized user amended the written directive and removed the sources at approximately 1300. The sources were placed in storage.
"The licensee notified the department on July 8, 2005. The Wisconsin Radiation Protection Section will investigate the medical event."
The State provided the following information via email:
"On July 6, 2005, a brachytherapy procedure to treat a bile duct carcinoma using 22 iridium-192 sources totaling 53.9 milliCuries in a ribbon with spacing of 0.5 centimeter between each source was performed. The ribbon was routed through the nasal gastric system to the treatment site (bile duct). A radiograph was taken of the source placement in the bile duct before releasing the patient to a hospital room. The radiograph verified the sources to be in the prescribed location.
"On July 7, 2005, a verification image was taken at 0850 and found that the radioactive sources had moved approximately 5 centimeters toward the gastrointestinal tract. The location of the sources was outside of the intended site. An attempt to reposition the source ribbon by the authorized user was unsuccessful. The authorized user amended the written directive and removed the sources at approximately 1300. The sources were placed in storage.
"The licensee notified the department on July 8, 2005. The Wisconsin Radiation Protection Section will investigate the medical event."