ENS 55980

v t e ENS Event
07:00 Jun 29, 2022
Title	Potential High Dose to Other than Treatment Site
Event Description	The following was received from the state of Oregon via email: On June 29, a deviation on the length of the transfer tube was identified where the tube was found to be 2.9 centimeters longer than the vendor's specification (122.9 cm vs. 120 cm). This tube is used specifically with Channel 1 of the afterloader [(source: 10 Ci Ir-192; model: VS2000; s/n: 02-01-0235-001-031622-11038-12)] with a tandem and ring (T and R) applicator. Treatments therefore will be 2.9 centimeters shorter than the programmed distance for treatments and involving 1.5-2 cm of unintended tissue which shall exceed 50 rem and quite probably 50 percent to the location. The transfer tube length was last measured on July 27, 2020 and the licensee noted that the tube "measured length appeared to reflect the specified length by the manufacturer at the time." Because of this, the licensee believes they may have under-dosed some of their T and R patients using this transfer tube with Channel 1 of the afterloader. The licensee has already indicated two T and R treatments where this may be the case, May 13 and June 22, and is putting together a list of all cases since the most recent tube length verification in 2020. Oregon Report ID Number: 22-0031 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.

ENS 55980 +/-
Where
Salem Hospital Salem, Oregon (NRC Region 4)
License number:	ORE-91006
Organization:	Or Dept Of Health Rad Protection
Reporting

Agreement State
Time - Person (Reporting Time:+201.05 h8.377 days <br />1.197 weeks <br />0.275 months <br />)
Opened:	Daryl Leon 16:03 Jul 7, 2022
NRC Officer:	Kerby Scales
Last Updated:	Jul 7, 2022
55980 - NRC Website
v • d • e

v t e Emergency Notification System
Salem Hospital with Agreement State
WEEKMONTHYEAR2022-06-29T07:00:00 [Table view]
[ENS list for Salem Hospital]

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