ENS Event | |
|---|---|
07:00 Oct 3, 2005 | |
| Title | Oregon Agreement State Report - Gamma Knife Treatment to the Incorrect Area of the Patient |
| Event Description | The State provided the following information via facsimile:
Doctor treated wrong Trigeminal nerve. Patient received 32 Gray before error was noted. Doctor informed patient of error then proceeded to treat correct nerve. In order to prevent a reoccurrence of this mistake, there will be three different double checks undertaken on the day of treatment. Prior to being sedated, the patient will be asked which side his or her pain is on. When the patient, is framed the nurse shall ask the neurosurgeon which side is to be treated. This will be verified with the patient. Lastly, just prior to treatment, both the neurosurgeon and the radiation oncologist will be once again asked which side is to be treated on the patient. This triple check system should prevent this mistake from happening again. |
| Where | |
|---|---|
| Porvidence Portland Medical Center Portland, Oregon (NRC Region 4) | |
| License number: | ORE-90946 |
| Organization: | Or Dept Of Health Rad Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+7788.58 h324.524 days <br />46.361 weeks <br />10.669 months <br />) | |
| Opened: | Kevin Siebert 19:35 Aug 23, 2006 |
| NRC Officer: | John Mackinnon |
| Last Updated: | Aug 23, 2006 |
| 42798 - NRC Website | |
Porvidence Portland Medical Center with Agreement State | |
WEEKMONTHYEARENS 427982005-10-03T07:00:0003 October 2005 07:00:00
[Table view]Agreement State Oregon Agreement State Report - Gamma Knife Treatment to the Incorrect Area of the Patient 2005-10-03T07:00:00 | |