ENS 55257: Difference between revisions
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| emergency class = Non Emergency | | emergency class = Non Emergency | ||
| notification date = 05/13/2021 20:41 | | notification date = 05/13/2021 20:41 | ||
| retracted = Yes | |||
| notification by = Robert Greger | | notification by = Robert Greger | ||
| NRC officer = Kerby Scales | | NRC officer = Kerby Scales | ||
| event date = 05/12/2021 00:00 | | event date = 05/12/2021 00:00 | ||
| last update date = | | last update date = 06/03/2021 | ||
| title = Overdose and Wrong Treatment Site | | title = Overdose and Wrong Treatment Site | ||
| event text = The following was received from the California Department of Public Health via email: | | event text = The following was received from the California Department of Public Health via email: | ||
On May 12, 2021, licensee notified the [Radiologic Health Branch] RHB of a possible medical event which occurred on May 10, 2021 involving a Gamma Knife patient who likely received a dose greater than 0.5 Sv (50 rem) to a tissue other than the treatment site and over 50% of the expected dose to that site from the procedure if the administration had been given in accordance with the written directive. No further details have been provided at this time. The licensee is currently investigating and will provide a full report within 15 days. RHB is investigating this event. | On May 12, 2021, licensee notified the [Radiologic Health Branch] RHB of a possible medical event which occurred on May 10, 2021 involving a Gamma Knife patient who likely received a dose greater than 0.5 Sv (50 rem) to a tissue other than the treatment site and over 50% of the expected dose to that site from the procedure if the administration had been given in accordance with the written directive. No further details have been provided at this time. The licensee is currently investigating and will provide a full report within 15 days. RHB is investigating this event. | ||
California Item Number: 051221 | California Item Number: 051221 | ||
* * * RETRACTION ON 1 JUNE 2021 AT 1454 EDT FROM L. ROBERT GREGER TO JOANNA BRIDGE * * * | |||
The following was received via e-mail from the state of California via e-mail: | |||
The licensee's initial dose calculation performed on the impacted non-target tissue was made to a non-dimensional point adjacent to the target tissue. Upon further licensee consideration, the non-target dose calculation was performed on the 1.55 cc non-target tissue (muscle) most impacted by a planning error for the gamma knife treatment. The revised calculation resulted in a dose to the non-target muscle tissue of 140 rad (1.4 Gy) compared to the 120 rad (1.2 Gy) that the 1.55 cc non-target muscle tissue would have received had the planning error not occurred. Therefore, the Medical Event criterion was not exceeded. | |||
Notified R4DO (Groom) and NMSS Events (by email). | |||
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. | 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. | ||
| URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2021/ | | URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2021/20210604en.html#en55257 | ||
}} | }} | ||
{{ENS-Nav}} | {{ENS-Nav}} | ||
Latest revision as of 07:30, 4 June 2021
| Where | |
|---|---|
| University Of California Davis Sacramento, California (NRC Region 4) | |
| License number: | CA-RML 1334-57 |
| Organization: | California Radiation Control Prgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+44.68 h1.862 days <br />0.266 weeks <br />0.0612 months <br />) | |
| Opened: | Robert Greger 20:41 May 13, 2021 |
| NRC Officer: | Kerby Scales |
| Last Updated: | Jun 3, 2021 |
| 55257 - NRC Website | |