ENS 41937

v t e ENS Event
19:05 Aug 22, 2005
Title	Part 21 - Gamma Knife Microphone Clip
Event Description	Lancaster General Hospital has been using a Leksell Model No. 23005 Type "B" Gamma Knife since 2000. The Gamma Knife unit has a metal clip which is velcroed to the patient's couch and it holds a microphone in which the patient can talk. A patient knocked the clip off, causing the clip to become detached from the couch (it was velcroed to the couch) and the microphone. The clip ended up in the Gamma Knife shielding. Due to the metal clip being stuck in the Gamma Knife shielding, the micro switches inside the Gamma Knife would not allow the jaws of the shielding to open. This prevented the patient from receiving the third treatment. Therefore the patient received only 2 out of 5 scheduled treatments (patient was under dosed) due to the clip failure. See event number 41928 called in by Lancaster General Hospital on 08/18/2005 for background information. UPDATE FROM MONTAGNESE TO KNOKE AT 12:07 EDT ON 09/07/05 *** The licensee discussed this event with Region 1 (Gabriel and Henderson). It was determined that this event did not meet 10 CFR 21.21 requirements and notification to the NRC under Part 21 was unnecessary. The notification for this medical event (EN 41928) is still in effect. Notifications were provided to R1DO (Holody), R2DO (Moorman), R3DO (Cameron), R4DO (Powers), NMSS (Morell) and Part 21 NMSS (Essig).

ENS 41937 +/-
Where
Leksell Lancaster, Pennsylvania (NRC Region 1)
License number:	37-11866-04
Organization:	Lancaster General Hospital
Reporting

10 CFR 21.21
Time - Person (Reporting Time:+-4 h-0.167 days <br />-0.0238 weeks <br />-0.00548 months <br />)
Opened:	Tony Montagnese 15:05 Aug 22, 2005
NRC Officer:	John Mackinnon
Last Updated:	Sep 7, 2005
41937 - NRC Website
v • d • e

v t e Emergency Notification System
Leksell with 10 CFR 21.21, Notification of failure to comply or existence of a defect and its evaluation
WEEKMONTHYEAR2005-08-22T19:05:00 [Table view]
[ENS list for Leksell]

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