ENS 47008

v t e ENS Event
04:00 Oct 25, 2007
Title	Agreement State Report - Medical Misadministration During Gamma Knife Therapy
Event Description	The following report was received via fax: On 10/25/2007, [the New York State Department of Health] received a call from a radiation oncology manager to report a therapy misadministration involving a gamma knife due to a machine malfunction, couch failure. The physicist and the neurosurgeon had to go in and manually pull the couch out. The physicist's badge was read on an emergency basis and showed DDE of 1 mRem and SDE of 2 mRem. The neurosurgeon did not have his badge on when he went in. The facility has treated about 125 patients in 4 years with the gamma knife unit, according to field notes from the inspection done in February 2007 and is close to the 5 year service requirement. The facility had planned to treat 10 lesions in the brain but stopped after 3 lesions were treated due to couch failure. The rest of the lesions were not treated with radiation. The patient had already received whole brain irradiation and received additional chemotherapy after the gamma knife procedure. Service performed: couch repaired. Policy & Procedure regarding film badge use reviewed during next routine inspection. This event is closed. New York Event: NY-11-15 New York Incident: 570 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 47008 +/-
Where
Ny Hospital New York, New York (NRC Region 1)
Organization:	New York State Dept. Of Health
Reporting

Agreement State
Time - Person (Reporting Time:+32287.32 h1,345.305 days <br />192.186 weeks <br />44.227 months <br />)
Opened:	Robert Snyder 11:19 Jul 1, 2011
NRC Officer:	Mark Abramovitz
Last Updated:	Jul 1, 2011
47008 - NRC Website
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v t e Emergency Notification System
Ny Hospital with Agreement State
WEEKMONTHYEAR2007-10-25T04:00:00 [Table view]
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