ENS 57972

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v t e ENS Event
05:00 Feb 26, 2025
Title	Medical Event
Event Description	The following information was provided by the Texas Department of State Health Services (the Department) via phone and email: On October 6, 2025, the Department received notification from the licensee regarding a treatment error during stereotactic radiosurgery with the gamma knife system for a patient with a brain arteriovenous malformation (AVM). The patient was prescribed 2 treatment sessions of 12 Gy each. The licensee stated that an error during the transfer from the frame coordinate system to the mask coordinate system resulted in radiation being delivered to an incorrect site in the brain. As a result, the dose delivered to the treatment site was less than the prescribed dose. The licensee stated that the event occurred in February 2025 and was discovered by the radiation oncology team during an internal review exercise of all AVM treatments provided by the licensee since 2016. This review was initiated following a similar incident involving the same procedure which the licensee had previously discovered on October 2, 2025, and reported to the Department on October 3, 2025 (see EN 57966). The licensee conducted this review to determine whether other patients had been affected by the same system error. According to the licensee, out of all cases reviewed, only this one met the criteria to be classified as a reportable event. Additional information will be provided in accordance with SA300 Reporting requirements. Texas incident number: 10235 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 57972 +/-
Where
Ut Sw Medical Center - Dallas Houston, Texas (NRC Region 4)
License number:	05947
Organization:	Texas Dept Of State Health Services
Reporting

Agreement State
Time - Person (Reporting Time:+5343.88 h222.662 days <br />31.809 weeks <br />7.32 months <br />)
Opened:	Sindiso Ncube 19:53 Oct 6, 2025
NRC Officer:	Robert A. Thompson
Last Updated:	Oct 6, 2025
57972 - NRC Website
v • d • e

v t e Emergency Notification System
Ut Sw Medical Center - Dallas with Agreement State
WEEKMONTHYEAR2025-09-25T05:00:00 [Table view]
[ENS list for Ut Sw Medical Center - Dallas]

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