Gamma Knife misadministration

[Walter cofer <cofer@NETTALLY.COM>]

Ed & list members -



I don't have a lot of details, but I was informed on Thursday that my 

agency has received a misadministration notification from a Florida 

hospital involving multiple Gamma Knife patients, and the cause appears to 

be tied to use of printer software, of all things.  I know a little more, 

but any further info would be premature because my agency has not 

investigated it yet.  We are sending an investigation team out early next 

week, and I'm sure that additional details will be forthcoming.



- Walter Cofer

FL Bureau of Radiation Control



-----Original Message-----

From:	Pombier, Edward C. [SMTP:epombier@MED.MIAMI.EDU]

Sent:	Friday, November 01, 2002 10:45 AM

To:	radsafe@list.vanderbilt.edu

Subject:	SPAM-ORDB: Gamma Knife



I have just been informed that the State of Florida does not want us to

treat any patients with our Gamma Knife until we verify that the printed

output correlates with the actual output of the unit.  Apparentlty this has

something to do with a new software upgrade or printer upgrade.  Does 

anyone

have any details about the problem, or if any misadministrations have

occurred.



Ed Pombier

University of Miami

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