ENS 46286
ENS Event | |
|---|---|
04:00 Sep 27, 2010 | |
| Title | Ohio Agreement State Report - 95% Medical Underdosage Due to Equipment Failure |
| Event Description | The following report was received from the State of Ohio via email:
On September 27, 2010, the Gamma Knife gave a Fatal Error and terminated treatment to a patient. The error appears to be a failed computer disc drive. The safety system of the Gamma Knife functioned as designed, moving the patient out of the treatment machine and closing the Gamma Knife doors. The patient was safely removed from the treatment room. A service representative was immediately contacted and repair of the Gamma Knife is in progress. It is intended to give the remaining dose from the plan to the patient once the Gamma Knife is repaired. The device in question is a Leksell, Model Perfexion Gamma Knife unit [S/N MV010], which contains a 13,824 Ci Co-60 source. The intended dose was 1400 rad. The delivered dose was 71.5 rad. The target organ was the brain. There is no effect on the patient. Ohio report #: OH100021.
On 11/9/10 the problem was diagnosed as faulty computer on unit. Computer was replaced and fully tested on 9/28/10. Patient remained in hospital overnight on 9/27/10 and received remainder of treatment on 9/28/10. No adverse effects anticipated due to delay in completing treatment. Licensee has contacted the manufacturer to review this incident for applicability to other units. Ohio Item Number 100021 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. |
| Where | |
|---|---|
| Cleveland Clinic Foundation Cleveland, Ohio (NRC Region 3) | |
| License number: | OH02110180013 |
| Organization: | Ohio Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+35.02 h1.459 days <br />0.208 weeks <br />0.048 months <br />) | |
| Opened: | Michael Snee 15:01 Sep 28, 2010 |
| NRC Officer: | Eric Simpson |
| Last Updated: | Nov 9, 2010 |
| 46286 - NRC Website | |
Cleveland Clinic Foundation with Agreement State | |
WEEKMONTHYEARENS 551572021-03-26T18:00:00026 March 2021 18:00:00
[Table view]Agreement State Medical Event Report - Underdosage ENS 536722018-10-16T04:00:00016 October 2018 04:00:00 Agreement State En Revision Imported Date 7/24/2019 ENS 498152014-01-24T05:00:00024 January 2014 05:00:00 Agreement State Agreement State Report - Medical Event Involving Unintended Dose ENS 470712011-07-12T15:00:00012 July 2011 15:00:00 Agreement State Agreement State Report - Patient Received Treatment to Incorrect Organ ENS 465722010-12-08T05:00:0008 December 2010 05:00:00 Agreement State Agreement State Report - Potential Underdose to Patient Due to Aborted Treatment ENS 463762010-10-29T04:00:00029 October 2010 04:00:00 Agreement State Agreement State - Dose Delivered to Wrong Organ ENS 462862010-09-27T04:00:00027 September 2010 04:00:00 Agreement State Ohio Agreement State Report - 95% Medical Underdosage Due to Equipment Failure ENS 443972008-08-07T18:00:0007 August 2008 18:00:00 Agreement State Agreement State Report - Underexposure During Hdr Medical Treatment Due to Equipment Malfunction ENS 405752004-03-04T21:00:0004 March 2004 21:00:00 Agreement State the Cleveland Clinic Foundation Administered an Underdose During a Therapeutic Treatment 2021-03-26T18:00:00 | |