ENS 41975

v t e ENS Event
04:00 Apr 9, 2003
Title	Patient Cough Caused Radiation Dose to Be Administered No More than 6 Millimeters from the Correct Site.
Event Description	A patient was having a hearing loss due to pressure (tumor inside the brain). The patient was being treated using a gamma knife. Toward the end of the patient's final treatment, toward the end of the 11 stage of the treatment plan, the patient coughed. The cough caused a pin used to stabilize the patient's skull to become dislodged (shifted). This resulted in the patient being administered a dose not directly to the tumor (dose administered no more than 6 millimeters from the correct area). No harm was caused to the patient. All physicians involved in the case were notified. The licensee has been discussing this event for the last couple of years and they were asked to report this event to the NRC Headquarters Operation Officer.

ENS 41975 +/-
Where
Washington Hospital Center Washington Dc, District Of Columbia (NRC Region 1)
License number:	08-03604-05
Organization:	Washington Hospital Center
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+21223.72 h884.322 days <br />126.332 weeks <br />29.072 months <br />)
Opened:	A. Eremia 11:43 Sep 9, 2005
NRC Officer:	John Mackinnon
Last Updated:	Sep 9, 2005
41975 - NRC Website
v • d • e

v t e Emergency Notification System
Washington Hospital Center with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2003-04-09T04:00:00 [Table view]
[ENS list for Washington Hospital Center]

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