Event Notification Report for January 05, 2018
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/04/2018 - 01/05/2018
EVENT NUMBERS
53168
Agreement State
Event Number: 53168
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: KYLE WALTON
HQ OPS Officer: DAVID AIRD
Licensee: ASPIRUS-WAUSAU HOSPITAL
Region: 3
City: WAUSAU State: WI
County:
License #: 073-1342-01
Agreement: Y
Docket:
NRC Notified By: KYLE WALTON
HQ OPS Officer: DAVID AIRD
Notification Date: 01/16/2018
Notification Time: 21:14 [ET]
Event Date: 01/05/2018
Event Time: 00:00 [CST]
Last Update Date: 01/18/2018
Notification Time: 21:14 [ET]
Event Date: 01/05/2018
Event Time: 00:00 [CST]
Last Update Date: 01/18/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
DAVID HILLS (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
DAVID HILLS (R3DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - DELIVERED DOSAGE DIFFERENT FROM PRESCRIBED
The following was received from the State of Wisconsin via email:
"An email the Department [Wisconsin Department of Health Services] received on January 5, 2018 was believed to be an update to the previous notification. 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 105 Gy. The licensee uses D90 (dose delivered to 90 percent of the clinical target volume) less than 80 percent for determining medical events. Using the licensee's dose based criteria; the dose received by the prostate was 62% of the intended dose.
"DHS inspectors will investigate this medical event."
Wisconsin Event: WI180001
The previous notification stated above, which occurred on January 4, 2018, is documented in EN# 53148.
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 following was received from the State of Wisconsin via email:
"An email the Department [Wisconsin Department of Health Services] received on January 5, 2018 was believed to be an update to the previous notification. 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 105 Gy. The licensee uses D90 (dose delivered to 90 percent of the clinical target volume) less than 80 percent for determining medical events. Using the licensee's dose based criteria; the dose received by the prostate was 62% of the intended dose.
"DHS inspectors will investigate this medical event."
Wisconsin Event: WI180001
The previous notification stated above, which occurred on January 4, 2018, is documented in EN# 53148.
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.