ENS 43950

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v t e ENS Event
18:30 Jan 31, 2008
Title	Agreement State Report - Equipment Safety Failure
Event Description	On Thursday, January 31, 2008 during a treatment of a patient an event occurred with the licensee's Leksell Gamma Knife Stereotactic teletherapy treatment unit (Model 24001 Type C). The patient treatment plan called for three exposure fractions. The first fraction was initiated at 10:25 a.m., without incident. After the normal termination time of treatment, the couch retracted fully and the patient's head was withdrawn from the unit. However, the shielding doors on the unit did not close. An Authorized Medical Physicist (AMP) then entered the treatment room, walked behind the unit, and closed the shielding doors manually. The licensee estimates that the AMP received an exposure of no more than 0.0083 mrem while closing the shielding doors. The patient was removed from the treatment room and a radiation survey was conducted to verify that the shielding doors had closed completely. Elekta was contacted (12:30 p.m. 01/31/08) and a service representative arrived and completed an evaluation of the Gamma Knife and could find no faults in any aspect of the Gamma Knife system operation. A decision was made by the Authorized User to complete the last two exposure factions. The remaining shots were successfully completed. The patient did not receive a radiation dose deviating from the written directive from the shielding doors not closing. The licensee was in constant contact with DHFS throughout this incident. This event will be followed up by DHFS on the next scheduled inspection (02/19/08). Event Report ID No WI-08-01 License No.: 79-1281-01 Event Type: HFS 157.13(17)(b)2.a - 'Equipment is disabled or thus to function as designed'

ENS 43950 +/-
Where
Aurora Health Care Metro Inc Milwaukee, Wisconsin (NRC Region 3)
License number:	79-1281-01
Organization:	Wisconsin Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+16.68 h0.695 days <br />0.0993 weeks <br />0.0228 months <br />)
Opened:	Jason Hunt 11:11 Feb 1, 2008
NRC Officer:	Joe O'Hara
Last Updated:	Feb 1, 2008
43950 - NRC Website
v • d • e

v t e Emergency Notification System
Aurora Health Care Metro Inc with Agreement State
WEEKMONTHYEAR2008-01-31T18:30:00 [Table view]
[ENS list for Aurora Health Care Metro Inc]

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