NRC: Recent Gamma Knife Misadministration

July 28, 2009 · Written by MDPhysics.com · mdphysicsblog@gmail.com

radiationsymbolOn July 27, 2009, the NRC reported that there has been a medical event at the Gamma Knife Center of the Pacific in Honolulu, Hawaii in which a patient received more than the prescribed dose of gamma radiation to two areas of the brain. Next week, the NRC is conducting a thorough inspection of the medical event, and the full report of the inspection will be available in about 1-2 months.

When the inspection report is completed and issued, it will be interesting to learn the licensee’s root cause and not only what steps were taken by the licensee to prevent such an incident from recurring, but also whether such steps are deemed adequate by the NRC. 

While news of misadministration is always scary and unfortunate, there is always a lesson to be learned by everyone to prevent a similar event from happening at any treatment center.

You can read the official NRC press release here:
http://www.nrc.gov/reading-rm/doc-collections/news/2009/09-027.iv.html

A link to the final inspection report as well as a follow-up post will be on this site when the NRC releases the report.

Posted in: Misadministration ·Tags: no tags

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