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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 41975 | 9 April 2003 04:00:00 | 10 CFR 35.3045(a)(1) | Patient Cough Caused Radiation Dose to Be Administered No More than 6 Millimeters from the Correct Site. | A patient was having a hearing loss due to pressure (tumor inside the brain). The patient was being treated using a gamma knife. Toward the end of the patient's final treatment, toward the end of the 11 stage of the treatment plan, the patient coughed. The cough caused a pin used to stabilize the patient's skull to become dislodged (shifted). This resulted in the patient being administered a dose not directly to the tumor (dose administered no more than 6 millimeters from the correct area). No harm was caused to the patient. All physicians involved in the case were notified. The licensee has been discussing this event for the last couple of years and they were asked to report this event to the NRC Headquarters Operation Officer. |