Event Notification Report for August 12, 2008
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/11/2008 - 08/12/2008
EVENT NUMBERS
46501
General Information
Event Number: 46501
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: MERCY MEDICAL CENTER
Region: 3
City: OSHKOSH State: WI
County:
License #: 139-1177-01
Agreement: Y
Docket:
NRC Notified By: MEGAN SHOBER
HQ OPS Officer: JOHN KNOKE
Licensee: MERCY MEDICAL CENTER
Region: 3
City: OSHKOSH State: WI
County:
License #: 139-1177-01
Agreement: Y
Docket:
NRC Notified By: MEGAN SHOBER
HQ OPS Officer: JOHN KNOKE
Notification Date: 12/21/2010
Notification Time: 12:30 [ET]
Event Date: 08/12/2008
Event Time: 00:00 [CST]
Last Update Date: 12/21/2010
Notification Time: 12:30 [ET]
Event Date: 08/12/2008
Event Time: 00:00 [CST]
Last Update Date: 12/21/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
ERIC DUNCAN (R3DO)
MICHELE BURGESS (FSME)
ERIC DUNCAN (R3DO)
MICHELE BURGESS (FSME)
AGREEMENT STATE REPORT - MEDICAL EVENT- PROSTATE BRACHYTHERAPY TREATMENT UNDERDOSE
This information was emailed by the state as follows:
"In July 2010, the Wisconsin Department of Health Services (DHS) sent out an Information Notice to all licensees who perform prostate brachytherapy and asked them to perform a retrospective review of all prostate brachytherapy cases to determine whether any medical events had occurred. On December 20, 2010, the licensee's Radiation Safety Officer notified DHS that on August 12, 2008 a patient received only 75.4 % of the prescribed dose during prostate brachytherapy using I-125 seeds. The patient was prescribed 145 Gy to the prostate, and based on a CT scan performed thirty days post-surgery, the licensee determined that the treatment delivered only 109.3 Gy to the prostate.
"The authorized user who treated this patient is no longer at the licensee's facility. The licensee is complying with the reporting criteria in DHS 157.72(1)(e) concerning notifications to the patient and referring physician. The licensee has already made process improvements (i.e. planning to higher D90 values) which have resulted in improved dosimetric coverage. DHS inspectors will follow up on the next routine inspection."
Event Report ID # WI100019
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.
This information was emailed by the state as follows:
"In July 2010, the Wisconsin Department of Health Services (DHS) sent out an Information Notice to all licensees who perform prostate brachytherapy and asked them to perform a retrospective review of all prostate brachytherapy cases to determine whether any medical events had occurred. On December 20, 2010, the licensee's Radiation Safety Officer notified DHS that on August 12, 2008 a patient received only 75.4 % of the prescribed dose during prostate brachytherapy using I-125 seeds. The patient was prescribed 145 Gy to the prostate, and based on a CT scan performed thirty days post-surgery, the licensee determined that the treatment delivered only 109.3 Gy to the prostate.
"The authorized user who treated this patient is no longer at the licensee's facility. The licensee is complying with the reporting criteria in DHS 157.72(1)(e) concerning notifications to the patient and referring physician. The licensee has already made process improvements (i.e. planning to higher D90 values) which have resulted in improved dosimetric coverage. DHS inspectors will follow up on the next routine inspection."
Event Report ID # WI100019
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.