ENS Event | |
|---|---|
04:00 Mar 8, 2012 | |
| Title | Agreement State Report - Gamma Knife Medical Overexposure |
| Event Description | The following information was received from the State of Florida via email:
Licensee reported a possible medical event on 8 March which was confirmed in a written report received on 22 March. Patient was being treated by Gamma Knife with 8 shots at four sites when the fifth shot was interrupted for a bathroom break. While in the bathroom the patient fell and dislodged the stereotactic frame. The frame was reapplied and treatment plan recalculated. However, the computer did not start the treatment at the correct site resulting in an increase in dose of 22.2% at site 2, 14.8% at site 3 & 15, and 7% at site 4. The doses are well within clinical practice. A conservative dose prescription had been elevated to a moderate prescription. The referring physician and patient have been notified. No medical consequences are expected. The cause is human error. Any further investigation referred to Licensing and Materials. No further action will be taken on this incident by this office. Device: Leksell Perfexion Serial Number: 6130 Florida Incident: FL-12-034 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 | |
|---|---|
| Larkin Community Hospital South Miami, Florida (NRC Region 1) | |
| License number: | 2825-2 |
| Organization: | Florida Bureau Of Radiation Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+533.12 h22.213 days <br />3.173 weeks <br />0.73 months <br />) | |
| Opened: | Charles Adams 08:07 Mar 30, 2012 |
| NRC Officer: | Mark Abramovitz |
| Last Updated: | Mar 30, 2012 |
| 47790 - NRC Website | |
Larkin Community Hospital with Agreement State | |
WEEKMONTHYEARENS 477902012-03-08T04:00:0008 March 2012 04:00:00
[Table view]Agreement State Agreement State Report - Gamma Knife Medical Overexposure 2012-03-08T04:00:00 | |