Event Notification Report for June 05, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/04/2021 - 06/05/2021
EVENT NUMBERS
55293
55293
Agreement State
Event Number: 55293
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: Advent Health Orlando
Region: 1
City: Orlando State: FL
County:
License #: 2897-1
Agreement: Y
Docket:
NRC Notified By: Matthew Senison
HQ OPS Officer: Jeffrey Whited
Licensee: Advent Health Orlando
Region: 1
City: Orlando State: FL
County:
License #: 2897-1
Agreement: Y
Docket:
NRC Notified By: Matthew Senison
HQ OPS Officer: Jeffrey Whited
Notification Date: 06/05/2021
Notification Time: 11:19 [ET]
Event Date: 06/05/2021
Event Time: 00:00 [EDT]
Last Update Date: 06/05/2021
Notification Time: 11:19 [ET]
Event Date: 06/05/2021
Event Time: 00:00 [EDT]
Last Update Date: 06/05/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
BICKETT, BRICE (R1DO)
WILLIAMS, KEVIN (NMSS)
MILLIGAN, PATRICIA (INES)
SMITH, TODD (INES)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
BICKETT, BRICE (R1DO)
WILLIAMS, KEVIN (NMSS)
MILLIGAN, PATRICIA (INES)
SMITH, TODD (INES)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 7/2/2021
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT
The following was received from the Florida Department of Health (FDH) via email:
"Source: Co-60, Gamma-Knife treatment
"Dose to brain lesion: 15 gray in Orlando, 18 gray in Colorado
"On April 27, a patient was consulted for a Co-60, Gamma-Knife treatment at Advent Health Orlando. The original [Adventist Health Orlando] Radiation Oncologist was made aware of previous treatment in Colorado and requested medical records. However, for two weeks in mid-May, the original Radiation Oncologist went on vacation. Then on May 14, the patient received Gamma Knife treatment from a different [Adventist Health Orlando] Radiation Oncologist. 13 brain lesions were treated. On May 17, the patient's records from Colorado were received by Advent Health Orlando, where on June 4 the original Radiation oncologist reviewed patient's records and discovered that, to 1 of the 13 lesions, the patient received 18 gray of treatment from a linear accelerator in Colorado, then received 15 gray of treatment from a Gamma Knife in Orlando. The Radiation Safety Officer (RSO) called [FDH] at 1000 EST on June 5, to report a potential medical event involving a duplicate treatment of a gamma knife to a patient.
"The patient and the physician have been notified. The RSO stated that in the future, but not the present, unintended clinical consequences to the patient's target organ are expected as a result of this incident."
Florida Event Number: FL21-074
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.
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT
The following was received from the Florida Department of Health (FDH) via email:
"Source: Co-60, Gamma-Knife treatment
"Dose to brain lesion: 15 gray in Orlando, 18 gray in Colorado
"On April 27, a patient was consulted for a Co-60, Gamma-Knife treatment at Advent Health Orlando. The original [Adventist Health Orlando] Radiation Oncologist was made aware of previous treatment in Colorado and requested medical records. However, for two weeks in mid-May, the original Radiation Oncologist went on vacation. Then on May 14, the patient received Gamma Knife treatment from a different [Adventist Health Orlando] Radiation Oncologist. 13 brain lesions were treated. On May 17, the patient's records from Colorado were received by Advent Health Orlando, where on June 4 the original Radiation oncologist reviewed patient's records and discovered that, to 1 of the 13 lesions, the patient received 18 gray of treatment from a linear accelerator in Colorado, then received 15 gray of treatment from a Gamma Knife in Orlando. The Radiation Safety Officer (RSO) called [FDH] at 1000 EST on June 5, to report a potential medical event involving a duplicate treatment of a gamma knife to a patient.
"The patient and the physician have been notified. The RSO stated that in the future, but not the present, unintended clinical consequences to the patient's target organ are expected as a result of this incident."
Florida Event Number: FL21-074
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.