Event Notification Report for February 10, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/09/2023 - 02/10/2023
EVENT NUMBERS
56349
56349
Agreement State
Event Number: 56349
Rep Org: Wisconsin Radiation Protection
Licensee: University of Wisconsin-Madison
Region: 3
City: Madison State: WI
County:
License #: 025-1323-01
Agreement: Y
Docket:
NRC Notified By: Megan Shober
HQ OPS Officer: Ian Howard
Licensee: University of Wisconsin-Madison
Region: 3
City: Madison State: WI
County:
License #: 025-1323-01
Agreement: Y
Docket:
NRC Notified By: Megan Shober
HQ OPS Officer: Ian Howard
Notification Date: 02/10/2023
Notification Time: 16:33 [ET]
Event Date: 02/10/2023
Event Time: 00:00 [CST]
Last Update Date: 02/10/2023
Notification Time: 16:33 [ET]
Event Date: 02/10/2023
Event Time: 00:00 [CST]
Last Update Date: 02/10/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Szwarc, Dariusz (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Szwarc, Dariusz (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following information was provided by the Wisconsin Radiation Protection Section via email:
"On February 10, 2023, the licensee reported a medical event which had occurred the previous day. A patient was being treated with a high dose rate remote after loader unit and the fraction required 17 needles. After the first 15 needles had been treated, the licensee noticed that the patient's needles had been pulled out approximately 2 cm from where they had been placed due to unexpected movement of the patient's bed. The licensee has not yet determined how the patient's bed moved, as the patient was sedated during treatment. Needles 16 and 17 were re-inserted and the dose to those needles was delivered as intended. The authorized user had prescribed 13.5 Gy to the treatment site for this fraction, and the licensee estimates that only 30 percent of the treatment volume received the prescribed dose. The referring physician and the patient's family have been notified."
Event Report ID No: WI230001
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 information was provided by the Wisconsin Radiation Protection Section via email:
"On February 10, 2023, the licensee reported a medical event which had occurred the previous day. A patient was being treated with a high dose rate remote after loader unit and the fraction required 17 needles. After the first 15 needles had been treated, the licensee noticed that the patient's needles had been pulled out approximately 2 cm from where they had been placed due to unexpected movement of the patient's bed. The licensee has not yet determined how the patient's bed moved, as the patient was sedated during treatment. Needles 16 and 17 were re-inserted and the dose to those needles was delivered as intended. The authorized user had prescribed 13.5 Gy to the treatment site for this fraction, and the licensee estimates that only 30 percent of the treatment volume received the prescribed dose. The referring physician and the patient's family have been notified."
Event Report ID No: WI230001
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.