ENS 56412

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v t e ENS Event
04:00 Mar 14, 2023
Title	Patient Treatment Suspended Prior to Completion
Event Description	The following information was provided by the New Jersey Department of Environmental Protection (DEP) via email: While receiving treatment with an Elekta Leksell Gamma Knife ICON unit, serial number 6135, the patient's treatment had to be suspended. During the administration of the treatment, after the conclusion of a prescribed shot, but before completion of the full treatment, the unit displayed an error that could not be resolved by licensee personnel and required a service technician. The treatment was consequently suspended. The service technician identified a worn sector drive as the cause of the malfunction. The dose administered versus the dose prescribed is still under discussion. The licensee will follow-up with a full report. NJ Event Report ID number: NJ-23-0001 * * UPDATE ON 3/16/23 AT 1513 EST FROM RICHARD PEROS TO BILL GOTT * * * Additional information has been obtained related to the initial notification provided on 3/15/23. The dose administered to the patient was only approximately 2.9 percent of the dose prescribed. The prescribed dose was 15 Gy. The unit malfunctioned after only 3 of the planned 13 shots was completed. 14.5589 Gy still needed to be administered out of the 15 Gy when the malfunction occurred. This incident therefore does qualify as a medical event as per 10 CFR 35.3045(a). Notified R1DO (Bickett) and NMSS Events Notification. 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 56412 +/-
Where
Hackensack University Medical Ctr Hackensack, New Jersey (NRC Region 1)
License number:	450695
Organization:	Nj Rad Prot And Rel Prevention Pgm
Reporting

Agreement State
Time - Person (Reporting Time:+33.28 h1.387 days <br />0.198 weeks <br />0.0456 months <br />)
Opened:	Richard Peros 13:17 Mar 15, 2023
NRC Officer:	Bill Gott
Last Updated:	Mar 16, 2023
56412 - NRC Website
v • d • e

v t e Emergency Notification System
Hackensack University Medical Ctr with Agreement State
WEEKMONTHYEAR2023-03-14T04:00:00 [Table view]
[ENS list for Hackensack University Medical Ctr]

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