ENS Event | |
|---|---|
05:00 Sep 30, 2010 | |
| Title | Texas Agreement State Report - Medical Event Involving Gamma Knife Therapy |
| Event Description | The following was received from the State of Texas via e-mail:
On October 1, 2010, the Agency [Texas Department of Health] received a phone call from the licensee's Radiation Safety Officer (RSO). The RSO stated that a medical event occurred on September 30, 2010, when, while conducting a single fraction exposure to a patient, the computer screen froze. The patient was immediately removed from the gamma knife device. Approximately five percent of the prescribed dose was delivered. The intended dose was 20 gray to one location, and 15 gray to a second location, both to be delivered simultaneously. The referring physician and patient have been notified of the event. The gamma knife is a Leksell Gamma Knife System, model number 24001 containing GE model 43047 sealed cobalt (Co) - 60 sources. Additional information will be provided as it is received in accordance with SA-300. This is Texas Incident #: I-8790. 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 | |
|---|---|
| Baylor Radiosurgery Center Dallas, Texas (NRC Region 4) | |
| License number: | 05842 |
| Organization: | Texas Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+30.83 h1.285 days <br />0.184 weeks <br />0.0422 months <br />) | |
| Opened: | Art Tucker 11:50 Oct 1, 2010 |
| NRC Officer: | Eric Simpson |
| Last Updated: | Oct 1, 2010 |
| 46300 - NRC Website | |
Baylor Radiosurgery Center with Agreement State | |
WEEKMONTHYEARENS 463002010-09-30T05:00:00030 September 2010 05:00:00
[Table view]Agreement State Texas Agreement State Report - Medical Event Involving Gamma Knife Therapy 2010-09-30T05:00:00 | |