ENS 53874

v t e ENS Event
05:00 Feb 12, 2019
Title	Agreement State Report - Potential Gamma Knife Treatment Underdose Received
Event Description	The following was received from the state of New Jersey via e-mail: While receiving treatment with an Elekta Leksell Gamma Knife Perfexion unit, serial number 6016, the patient's head may have slipped forward in the stereotactic frame by two millimeters. This was not noticed until after the treatment was completed. The licensee is not sure when the slippage occurred. If the movement occurred during treatment, the dose received would have been 50 percent of the prescribed dose. The authorized user and authorized medical physicist are in discussions with the Radiation Safety Officer concerning the matter. The licensee will follow-up with a full report. 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 53874 +/-
Where
Cooper Health Systems Camden, New Jersey (NRC Region 1)
License number:	438814
Organization:	Nj Rad Prot And Rel Prevention Pgm
Reporting

Agreement State
Time - Person (Reporting Time:+32.48 h1.353 days <br />0.193 weeks <br />0.0445 months <br />)
Opened:	Richard Peros 13:29 Feb 13, 2019
NRC Officer:	Jeffrey Whited
Last Updated:	Feb 13, 2019
53874 - NRC Website
v • d • e

v t e Emergency Notification System
Cooper Health Systems with Agreement State
WEEKMONTHYEAR2019-02-12T05:00:00 [Table view]
[ENS list for Cooper Health Systems]

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