ENS 45716

v t e ENS Event
15:45 Feb 23, 2010
Title	Agreement State Report - Gamma Knife Treatment to Wrong Location
Event Description	A gamma knife treatment prescribed to be administered to the left side of a patient was instead administered to the patient's right side. The scheduled 30 minute, 90 Gray procedure was terminated after 1.4 minutes when the administering physician detected the error. It is estimated that 4% of the prescribed dose was administered to the wrong area. 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 45716 +/-
Where
University Of Kentucky Lexington, Kentucky (NRC Region 1)
Organization:	Kentucky Dept Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+-1.82 h-0.0758 days <br />-0.0108 weeks <br />-0.00249 months <br />)
Opened:	Marissa Vega Velez 13:56 Feb 23, 2010
NRC Officer:	Dan Livermore
Last Updated:	Feb 23, 2010
45716 - NRC Website
v • d • e

v t e Emergency Notification System
University Of Kentucky with Agreement State
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