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. |
| 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 | |
Cooper Health Systems with Agreement State | |
WEEKMONTHYEARENS 538742019-02-12T05:00:00012 February 2019 05:00:00
[Table view]Agreement State Agreement State Report - Potential Gamma Knife Treatment Underdose Received 2019-02-12T05:00:00 | |