ENS 42798

v t e 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.

ENS 42798 +/-
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
v • d • e

v t e Emergency Notification System
Porvidence Portland Medical Center with Agreement State
WEEKMONTHYEAR2005-10-03T07:00:00 [Table view]
[ENS list for Porvidence Portland Medical Center]

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