ENS Event | |
|---|---|
04:00 Jun 5, 2021 | |
| Title | Medical Event |
| Event Description | The following was received from the Florida Department of Health (FDH) via email:
Source: Co-60, Gamma-Knife treatment Dose to brain lesion: 15 gray in Orlando, 18 gray in Colorado On April 27, a patient was consulted for a Co-60, Gamma-Knife treatment at Advent Health Orlando. The original [Adventist Health Orlando] Radiation Oncologist was made aware of previous treatment in Colorado and requested medical records. However, for two weeks in mid-May, the original Radiation Oncologist went on vacation. Then on May 14, the patient received Gamma Knife treatment from a different [Adventist Health Orlando] Radiation Oncologist. 13 brain lesions were treated. On May 17, the patient's records from Colorado were received by Advent Health Orlando, where on June 4 the original Radiation oncologist reviewed patient's records and discovered that, to 1 of the 13 lesions, the patient received 18 gray of treatment from a linear accelerator in Colorado, then received 15 gray of treatment from a Gamma Knife in Orlando. The Radiation Safety Officer (RSO) called [FDH] at 1000 EST on June 5, to report a potential medical event involving a duplicate treatment of a gamma knife to a patient. The patient and the physician have been notified. The RSO stated that in the future, but not the present, unintended clinical consequences to the patient's target organ are expected as a result of this incident. Florida Event Number: FL21-074 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 | |
|---|---|
| Advent Health Orlando Orlando, Florida (NRC Region 1) | |
| License number: | 2897-1 |
| Organization: | Florida Bureau Of Radiation Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+7.32 h0.305 days <br />0.0436 weeks <br />0.01 months <br />) | |
| Opened: | Matthew Senison 11:19 Jun 5, 2021 |
| NRC Officer: | Jeffrey Whited |
| Last Updated: | Jun 5, 2021 |
| 55293 - NRC Website | |
Advent Health Orlando with Agreement State | |
WEEKMONTHYEARENS 552932021-06-05T04:00:0005 June 2021 04:00:00
[Table view]Agreement State Medical Event ENS 552942021-06-03T04:00:0003 June 2021 04:00:00 Agreement State the Following Was Received from the Florida Department of Health Via Email: 2021-06-05T04:00:00 | |