ENS Event | |
|---|---|
04:00 Oct 2, 2015 | |
| Title | Agreement State Report - Gamma Knife Treatment To Incorrect Location |
| Event Description | The following report was received via e-mail:
A Gamma Knife patient with trigeminal neuralgia was treated to the incorrect side. The intended side was the patient's right, however, the left side was treated. The prescription was 85 Gy @ 100%. The intended volume was approximately only 33.5 cubic mm which corresponds to the 80% isodose (68 Gy). The incorrect treatment location was determined as the patient completed treatment at approximately 1000 EDT. Once the situation was reviewed, discussed and confirmed by those involved with this treatment, the Radiation Safety Officer (RSO) was notified via phone call at approximately 1100 EDT. The RSO stated that he would contact the State to report the event. The patient has already been informed regarding what happened by the attending neurosurgeon, and after a short break, the patient was then treated to the correct side. The correct treatment was completed at approximately 1230 EDT. The attending radiation oncologist notified the referring physician practice at approximately 1400 EDT. Licensee will provide a required report within 15 days. They are still determining corrective actions to prevent reoccurrence. A state inspector will be on-site doing a follow up investigation Monday, 10/5/2015. The treatment isocenter was positioned incorrectly due to human error. More details to be gathered during site visit and investigation by Agency [North Carolina Division of Health and Human Services] scheduled for 1000 EDT, Monday, October 5, 2015. Corrective actions are being discussed by licensee. Note: Licensee radiation team and referring physician do not believe patient will suffer any acute deleterious effects at this time. North Carolina NMED #NC150026 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 | |
|---|---|
| Wake Forest Baptist Health Winston-Salem, North Carolina (NRC Region 1) | |
| License number: | 034-0158-8 |
| Organization: | Nc Div Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+13.98 h0.583 days <br />0.0832 weeks <br />0.0191 months <br />) | |
| Opened: | David Crowley 17:59 Oct 2, 2015 |
| NRC Officer: | Mark Abramovitz |
| Last Updated: | Oct 2, 2015 |
| 51442 - NRC Website | |
Wake Forest Baptist Health with Agreement State | |
WEEKMONTHYEARENS 514422015-10-02T04:00:0002 October 2015 04:00:00
[Table view]Agreement State Agreement State Report - Gamma Knife Treatment to Incorrect Location 2015-10-02T04:00:00 | |