ENS Event | |
|---|---|
05:00 Sep 25, 2025 | |
| Title | Medical Event |
| Event Description | The following information was provided by the Texas Department of State Health Services (the Department) via phone and email:
On October 3, 2025, the Department received notification from the licensee regarding a treatment error during stereotactic radiosurgery with a gamma knife system for a patient with a brain arteriovenous malformation (AVM). The patient was prescribed a total dose of 20 Gy over 2 fractions. The licensee stated that the event occurred on September 25, 2025, when during the first fraction, a coordinate system error between the stereotactic frame and immobilization masking resulted in radiation being delivered to an incorrect site in the brain, completely missing the AVM target volume. As a result, the prescribed 12 Gy for the first fraction was delivered to non-target brain tissue and 0 Gy reached the intended AVM target. The error was discovered on October 2, 2025, just before the patient was scheduled to undergo the second and final treatment fraction. Treatment was immediately suspended and both the referring physician, who is the surgeon, and the patient were immediately informed. Additional information will be provided in accordance with SA-300 reporting requirements. Texas incident number: 10231 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 | |
|---|---|
| Ut Sw Medical Center - Dallas Dallas, Texas (NRC Region 4) | |
| License number: | 05947 |
| Organization: | Texas Dept Of State Health Services |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+202.38 h8.433 days <br />1.205 weeks <br />0.277 months <br />) | |
| Opened: | Sindiso Ncube 15:23 Oct 3, 2025 |
| NRC Officer: | Robert A. Thompson |
| Last Updated: | Oct 3, 2025 |
| 57966 - NRC Website | |
Ut Sw Medical Center - Dallas with Agreement State | |
WEEKMONTHYEARENS 579662025-09-25T05:00:00025 September 2025 05:00:00
[Table view]Agreement State Medical Event ENS 579722025-02-26T05:00:00026 February 2025 05:00:00 Agreement State Medical Event 2025-09-25T05:00:00 | |