ENS 55293

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v t e ENS Event
04:00 Jun 5, 2021
Title	Medical Event
Event Description	The following was received from the Florida Department of Health (FDH) via email: Source: Co-60, Gamma-Knife treatment Dose to brain lesion: 15 gray in Orlando, 18 gray in Colorado On April 27, a patient was consulted for a Co-60, Gamma-Knife treatment at Advent Health Orlando. The original [Adventist Health Orlando] Radiation Oncologist was made aware of previous treatment in Colorado and requested medical records. However, for two weeks in mid-May, the original Radiation Oncologist went on vacation. Then on May 14, the patient received Gamma Knife treatment from a different [Adventist Health Orlando] Radiation Oncologist. 13 brain lesions were treated. On May 17, the patient's records from Colorado were received by Advent Health Orlando, where on June 4 the original Radiation oncologist reviewed patient's records and discovered that, to 1 of the 13 lesions, the patient received 18 gray of treatment from a linear accelerator in Colorado, then received 15 gray of treatment from a Gamma Knife in Orlando. The Radiation Safety Officer (RSO) called [FDH] at 1000 EST on June 5, to report a potential medical event involving a duplicate treatment of a gamma knife to a patient. The patient and the physician have been notified. The RSO stated that in the future, but not the present, unintended clinical consequences to the patient's target organ are expected as a result of this incident. Florida Event Number: FL21-074 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 55293 +/-
Where
Advent Health Orlando Orlando, Florida (NRC Region 1)
License number:	2897-1
Organization:	Florida Bureau Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+7.32 h0.305 days <br />0.0436 weeks <br />0.01 months <br />)
Opened:	Matthew Senison 11:19 Jun 5, 2021
NRC Officer:	Jeffrey Whited
Last Updated:	Jun 5, 2021
55293 - NRC Website
v • d • e

v t e Emergency Notification System
Advent Health Orlando with Agreement State
WEEKMONTHYEAR2021-06-05T04:00:00 [Table view]
[ENS list for Advent Health Orlando]

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