ENS Event | |
|---|---|
00:00 May 12, 2021 | |
| Title | Overdose and Wrong Treatment Site |
| Event Description | The following was received from the California Department of Public Health via email:
On May 12, 2021, licensee notified the [Radiologic Health Branch] RHB of a possible medical event which occurred on May 10, 2021 involving a Gamma Knife patient who likely received a dose greater than 0.5 Sv (50 rem) to a tissue other than the treatment site and over 50% of the expected dose to that site from the procedure if the administration had been given in accordance with the written directive. No further details have been provided at this time. The licensee is currently investigating and will provide a full report within 15 days. RHB is investigating this event. California Item Number: 051221
The following was received via e-mail from the state of California via e-mail: The licensee's initial dose calculation performed on the impacted non-target tissue was made to a non-dimensional point adjacent to the target tissue. Upon further licensee consideration, the non-target dose calculation was performed on the 1.55 cc non-target tissue (muscle) most impacted by a planning error for the gamma knife treatment. The revised calculation resulted in a dose to the non-target muscle tissue of 140 rad (1.4 Gy) compared to the 120 rad (1.2 Gy) that the 1.55 cc non-target muscle tissue would have received had the planning error not occurred. Therefore, the Medical Event criterion was not exceeded. Notified R4DO (Groom) and NMSS Events (by email). 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 | |
|---|---|
| University Of California Davis Sacramento, California (NRC Region 4) | |
| License number: | CA-RML 1334-57 |
| Organization: | California Radiation Control Prgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+44.68 h1.862 days <br />0.266 weeks <br />0.0612 months <br />) | |
| Opened: | Robert Greger 20:41 May 13, 2021 |
| NRC Officer: | Kerby Scales |
| Last Updated: | Jun 3, 2021 |
| 55257 - NRC Website | |
University Of California Davis with Agreement State | |
WEEKMONTHYEARENS 552572021-05-12T00:00:00012 May 2021 00:00:00
[Table view]Agreement State Overdose and Wrong Treatment Site ENS 496552013-12-18T08:00:00018 December 2013 08:00:00 Agreement State Agreement State Report - Lost Material Shipment 2021-05-12T00:00:00 | |