ENS Event | |
|---|---|
17:00 Oct 20, 2017 | |
| Title | Agreement State Report - Gamma Knife Malfunction |
| Event Description | On 10/20/17, at 1000 PDT, a Gamma knife treatment was in process when the machine malfunctioned and recorded an error. The backup battery on the UPS (Uninterruptible Power Source) was low and resulted in the machine pausing and returning the source to the shielded position. The patient received approximately one third of the prescribed dose. The service provider was contacted and is scheduled to report to the hospital today (10/23/2017) to replace the backup battery.
Elekta Leksell Gamma Knife Model Perfexion Serial number NM-001-NM201 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. |
| Where | |
|---|---|
| Providence Health Services Oregon Portland, Oregon (NRC Region 4) | |
| License number: | Ore-90946 |
| Organization: | Or Dept Of Health Rad Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+67.57 h2.815 days <br />0.402 weeks <br />0.0926 months <br />) | |
| Opened: | Darly Leon 12:34 Oct 23, 2017 |
| NRC Officer: | Steven Vitto |
| Last Updated: | Oct 23, 2017 |
| 53032 - NRC Website | |
Providence Health Services Oregon with Agreement State | |
WEEKMONTHYEARENS 530322017-10-20T17:00:00020 October 2017 17:00:00
[Table view]Agreement State Agreement State Report - Gamma Knife Malfunction 2017-10-20T17:00:00 | |