ENS Event | |
|---|---|
04:00 Mar 14, 2023 | |
| Title | Patient Treatment Suspended Prior to Completion |
| Event Description | The following information was provided by the New Jersey Department of Environmental Protection (DEP) via email:
While receiving treatment with an Elekta Leksell Gamma Knife ICON unit, serial number 6135, the patient's treatment had to be suspended. During the administration of the treatment, after the conclusion of a prescribed shot, but before completion of the full treatment, the unit displayed an error that could not be resolved by licensee personnel and required a service technician. The treatment was consequently suspended. The service technician identified a worn sector drive as the cause of the malfunction. The dose administered versus the dose prescribed is still under discussion. The licensee will follow-up with a full report. NJ Event Report ID number: NJ-23-0001
Additional information has been obtained related to the initial notification provided on 3/15/23. The dose administered to the patient was only approximately 2.9 percent of the dose prescribed. The prescribed dose was 15 Gy. The unit malfunctioned after only 3 of the planned 13 shots was completed. 14.5589 Gy still needed to be administered out of the 15 Gy when the malfunction occurred. This incident therefore does qualify as a medical event as per 10 CFR 35.3045(a). Notified R1DO (Bickett) and NMSS Events Notification. 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 | |
|---|---|
| Hackensack University Medical Ctr Hackensack, New Jersey (NRC Region 1) | |
| License number: | 450695 |
| Organization: | Nj Rad Prot And Rel Prevention Pgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+33.28 h1.387 days <br />0.198 weeks <br />0.0456 months <br />) | |
| Opened: | Richard Peros 13:17 Mar 15, 2023 |
| NRC Officer: | Bill Gott |
| Last Updated: | Mar 16, 2023 |
| 56412 - NRC Website | |
Hackensack University Medical Ctr with Agreement State | |
WEEKMONTHYEARENS 564122023-03-14T04:00:00014 March 2023 04:00:00
[Table view]Agreement State Patient Treatment Suspended Prior to Completion 2023-03-14T04:00:00 | |