Event Notification Report for March 09, 2009
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/08/2009 - 03/09/2009
EVENT NUMBERS
44895
General Information or Other
Event Number: 44895
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: AURORA HEALTH CENTER
Region: 3
City: SHEBOYGAN State: WI
County:
License #: 117-1022-01
Agreement: Y
Docket:
NRC Notified By: LEOLA DEKOCK
HQ OPS Officer: DONALD NORWOOD
Licensee: AURORA HEALTH CENTER
Region: 3
City: SHEBOYGAN State: WI
County:
License #: 117-1022-01
Agreement: Y
Docket:
NRC Notified By: LEOLA DEKOCK
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/11/2009
Notification Time: 14:00 [ET]
Event Date: 03/09/2009
Event Time: 00:00 [CDT]
Last Update Date: 03/11/2009
Notification Time: 14:00 [ET]
Event Date: 03/09/2009
Event Time: 00:00 [CDT]
Last Update Date: 03/11/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
JULIO LARA (R3)
ANGELA MCINTOSH (FSME)
JULIO LARA (R3)
ANGELA MCINTOSH (FSME)
AGREEMENT STATE REPORT - PROSTATE BRACHYTHERAPY OVERDOSE
"The Wisconsin Radiation Protection Section (RPS) was notified on 3/10/09 of a possible medical event that occurred on 3/9/09. The medical event occurred at Lombardi Cancer Center, which is affiliated with Aurora Health Center in Sheboygan (RML #117-1022-01).
"The treatment was a permanent prostate brachytherapy implant using I-125 seeds. The intended total dose was 107 Gy and the patient was administered a total dose of 144 Gy. The overdose was discovered on 3/9/09, following review by the dosimetrist.
"The patient was notified on 3/10/09. The referring urologist and the patient's primary care provider were also notified.
"RPS has had telephone communications with the RSO and the Authorized User (AU) and has requested additional documents. The RSO will be unavailable (out-of-town). A team of RPS staff will be conducting a site visit at the facility when the AU returns."
Wisconsin Radiation Protection Section Event Report ID Number: WI090003.
An on-site investigation is planned by Wisconsin Radiation Protection Section beginning 3/12/09. A follow-up report will be issued after the investigation is completed.
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.
"The Wisconsin Radiation Protection Section (RPS) was notified on 3/10/09 of a possible medical event that occurred on 3/9/09. The medical event occurred at Lombardi Cancer Center, which is affiliated with Aurora Health Center in Sheboygan (RML #117-1022-01).
"The treatment was a permanent prostate brachytherapy implant using I-125 seeds. The intended total dose was 107 Gy and the patient was administered a total dose of 144 Gy. The overdose was discovered on 3/9/09, following review by the dosimetrist.
"The patient was notified on 3/10/09. The referring urologist and the patient's primary care provider were also notified.
"RPS has had telephone communications with the RSO and the Authorized User (AU) and has requested additional documents. The RSO will be unavailable (out-of-town). A team of RPS staff will be conducting a site visit at the facility when the AU returns."
Wisconsin Radiation Protection Section Event Report ID Number: WI090003.
An on-site investigation is planned by Wisconsin Radiation Protection Section beginning 3/12/09. A follow-up report will be issued after the investigation is completed.
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.