ENS Event | |
|---|---|
16:45 May 31, 2017 | |
| Title | Medical Event - Patient Received Less Dose than Prescribed |
| Event Description | On May 31, 2017, the licensee's gamma knife model 'C' failed during treatment delivery. The couch retracted from the treatment position at 1245 [EDT] due to a clutch malfunction. Three out of five shots were delivered to the single planned lesion. The prescribed volume received a dose of 15 Gy versus the prescribed 20 Gy. Due to uncertainty regarding repair, the fixation frame was removed from the patient's head. Repair was completed at 1845 [EDT]."
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 | |
|---|---|
| Karmanos Cancer Institute Detroit, Michigan (NRC Region 3) | |
| License number: | 21-04127-06 |
| Organization: | Karmanos Cancer Institute |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+19.67 h0.82 days <br />0.117 weeks <br />0.0269 months <br />) | |
| Opened: | Joe Rakowski 12:25 Jun 1, 2017 |
| NRC Officer: | Dong Park |
| Last Updated: | Jun 1, 2017 |
| 52780 - NRC Website
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Karmanos Cancer Institute with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 527802017-05-31T16:45:00031 May 2017 16:45:00
[Table view]10 CFR 35.3045(a)(1) Medical Event - Patient Received Less Dose than Prescribed ENS 451742008-02-18T16:00:00018 February 2008 16:00:00 10 CFR 35.3045(a)(1) Medical Event Involving a Dose That Is Different than Prescribed 2017-05-31T16:45:00 | |