ENS 49049

v t e ENS Event
04:00 May 17, 2013
Title	Massachusetts Agreement State Report - Medical Event Concerning Gamma Knife Therapy
Event Description	A patient was undergoing a second gamma knife treatment when the treatment was delivered to the wrong side of the brain. The patient and the prescribing physician were informed. The patient received 75 Gy to the brain. No serious effects are expected. The Commonwealth of Massachusetts will be providing an update to this event. 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. * * UPDATE FROM MICHAEL WHALEN TO JOHN SHOEMAKER AT 1350 EDT ON 5/20/13 * * * The following report was received via email. Event Occurred on 5/17/2013 at approximately 1000 [EDT]. With a Gamma Knife Manufacturer: Leksell Gamma System Model: Model 24001 Type C Sealed Sources information: Manufacturer: Elekta Model number: 43685 Prescribed treatment was for one fraction [the daily dose] of 75 Grays to be delivered to the left side of brain. However, the right side of the brain received the treatment. Notified R1DO (Gray) and FSME EVENTS RESOURCE via email.

ENS 49049 +/-
Where
Tufts Medical Center Boston, Massachusetts (NRC Region 1)
License number:	68-0263
Organization:	Ma Radiation Control Program
Reporting

Agreement State
Time - Person (Reporting Time:+12.92 h0.538 days <br />0.0769 weeks <br />0.0177 months <br />)
Opened:	Marie Ward 16:55 May 17, 2013
NRC Officer:	Howie Crouch
Last Updated:	May 20, 2013
49049 - NRC Website
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v t e Emergency Notification System
Tufts Medical Center with Agreement State
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