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Start date | Reporting criterion | Title | Event description | System | LER | |
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ENS 55607 | 19 November 2021 17:00:00 | Agreement State | Gamma Knife Shutter Doors Fail to Close | The following report was received via email from the New Jersey Department of Environmental Protection: While conducting the routine spot check prior to patient treatment with an Elekta Leksell Gamma Knife ICON unit, serial number 6114, the unit's shutter doors failed to close during the "Emergency Off" button test. The licensee's authorized medical physicist (AMP) followed emergency procedures and entered the room to manually close the doors. The doors closed, but the AMP decided to try again with the same result. The AMP carried a handheld survey meter with them each trip. Their calculated total exposure for their trips based on the exposure rate was 0.575 mR. There was no patient involvement. The unit is secured and Elekta is in the process repairing the unit. The licensee will follow-up with a full report. |