ENS 50868

v t e ENS Event
08:00 Mar 4, 2015
Title	Agreement State Report - Potential Medical Events Due to a Misaligned Gamma Knife
Event Description	On March 4, 2015, the licensee notified the State of Oregon that they discovered that their Elekta Leksell Gamma Knife was off target by approximately 1.87mm. This was allegedly due to maintenance performed in early January 2015, that resulted in a misaligned couch. Since the misalignment, eight patients have undergone gamma knife surgery. The licensee Medical Physicist is currently evaluating each case to determine whether an underdose/overdose occurred to any of the patients. The Elekta Leksell Gamma Knife is licensed for up to 6.6 kCi of Co-60. The State of Oregon will update this report as more information becomes available. 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 50868 +/-
Where
Legacy Good Samaritan Medical Center Portland, Oregon (NRC Region 4)
License number:	ORE-91155
Organization:	Or Dept Of Health Rad Protection
Reporting

Agreement State
Time - Person (Reporting Time:+33.63 h1.401 days <br />0.2 weeks <br />0.0461 months <br />)
Opened:	Daryl Leon 17:38 Mar 5, 2015
NRC Officer:	Howie Crouch
Last Updated:	Mar 5, 2015
50868 - NRC Website
v • d • e

v t e Emergency Notification System
Legacy Good Samaritan Medical Center with Agreement State
WEEKMONTHYEAR2015-03-04T08:00:00 [Table view]
[ENS list for Legacy Good Samaritan Medical Center]

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