ENS 45249

v t e ENS Event
04:00 Aug 5, 2009
Title	Dosage to Patient Was Potentially Different from Prescribed Dose Due to Equipment Malfunction
Event Description	Two patients were scheduled for treatment using a Leksell GammaKnife Model C/B-2 stereotactic radiosurgery unit on August 5, 2009. This model uses an Automatic Positioning System (APS) to automatically change patient position during the treatment. The APS reported positioning error codes to the treatment console and the operators called Elekta, the manufacturer's US representative for help. They were told to undock the patient and reinitialize the APS system and then to complete treatment. This happened again during the second patient treatment and the local Elekta service person was called to inspect the unit. The service representative arrived after the completion of treatment to the second patient and it was noted then that while trying to drive the APS system back to it's nominal position, one of the axis indicators was off by 5 mm. It is not known if this happened during the treatment, so this is a provisional report until a thorough analysis can be performed. The console logs have to be analyzed by the manufacturer's representatives to see if the error occurred during treatment and as a result of an APS malfunction. A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

ENS 45249 +/-
Where
Yale - New Haven Hospital New Haven, Connecticut (NRC Region 1)
License number:	06-30445-01
Organization:	Yale - New Haven Hospital
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+32.18 h1.341 days <br />0.192 weeks <br />0.0441 months <br />)
Opened:	Mike Bohan 12:11 Aug 6, 2009
NRC Officer:	John Knoke
Last Updated:	Aug 6, 2009
45249 - NRC Website
v • d • e

v t e Emergency Notification System
Yale - New Haven Hospital with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2009-08-05T04:00:00 [Table view]
[ENS list for Yale - New Haven Hospital]

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