ENS Event | |
|---|---|
04:00 Dec 15, 2008 | |
| Title | Incident Involving Co-60 Gamma Knife During Patient Treatment |
| Event Description | The following information was provided by the state via e-mail:
During an inspection on March 17 through 19, 2009, the ODH [Ohio Department of Health] inspector identified through the licensee's radiation safety committee meeting minutes an incident involving the Co-60 Gamma Knife that occurred on December 15, 2008, at approximately 2:15 pm. During a patient treatment, the couch moved out of treatment position. The emergency stop button was activated and the system did not respond. The licensee's staff had to manually pull out the couch from the Gamma Knife and manually close the doors to the Gamma Knife to shield the source. According to the licensee, radiation exposure to all individuals involved with the incident was minimal. The incident DID NOT result in a medical event for the patient. The manufacturer (Elekta) was immediately contacted and the Gamma Knife was repaired. Patient treatment was resumed and completed without incident. According to Elekta, the Gamma Knife system experienced an illegal couch sensor error due to a known software bug problem. The licensee failed to notify the Ohio Department of Health, Bureau of Radiation Protection of this device failure and therefore this is determined to be non-compliant with the provisions of rule 3701:1-40-20 (B)(2)(a,b,c) of the Ohio Administrative Code. Ohio State Reference Number: OH 2009-008 |
| Where | |
|---|---|
| University Hospitals Of Cleveland Cleveland, Ohio (NRC Region 3) | |
| License number: | 02110180077 |
| Organization: | Ohio Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+2698 h112.417 days <br />16.06 weeks <br />3.696 months <br />) | |
| Opened: | Stephen James 13:00 Apr 6, 2009 |
| NRC Officer: | Joe O'Hara |
| Last Updated: | Apr 6, 2009 |
| 44973 - NRC Website | |
University Hospitals Of Cleveland with Agreement State | |
WEEKMONTHYEARENS 551522019-06-12T04:00:00012 June 2019 04:00:00
[Table view]Agreement State Failure to Report Underdose to Patient ENS 512332015-07-14T14:30:00014 July 2015 14:30:00 Agreement State Agreement State Report - Dose to Improper Treatment Site ENS 449732008-12-15T04:00:00015 December 2008 04:00:00 Agreement State Incident Involving Co-60 Gamma Knife During Patient Treatment 2019-06-12T04:00:00 | |