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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 51978 | 31 May 2016 04:00:00 | Agreement State | Agreement State Report - Leaking Source | The following information was received by the State of Ohio via email: Leak test of sealed source indicated greater than 185 Bq (0.005 microCi) of removable contamination. Cs-137 vial source, 177 microCi, 44,000 cpm removable. Several wipes were performed as well as a measurement with a multi-channel analyzer to confirm the radioisotope. The source was placed in a lead pig, taped closed, labeled as a leaking sealed source, and placed in the main hot lab hot-waste storage container. Area wipes were performed to verify that no contamination was present in the vicinity. The source has been removed from service. Serial Number: 1074-22-5 Ohio Item Number: OH160005
After further review, report OH160005 previously submitted to the Ops Center was not subject to 24-hour notification. Notified R3DO (Hills) and NMSS Events Notification via email. | ||
| ENS 49770 | 24 January 2014 05:00:00 | Agreement State | Agreeement State Report - Patient Received Less than Prescribed Dose | The following was received from the State of Ohio via email: On Jan. 27, 2014, the RSO of Flower Hospital provided a telephone report of medical event that occurred on Jan. 24 and 27, 2014. A patient was being treated with a Varian GammaMed Plus HDR with 4.7 Ci of lr-192 in a vaginal cylinder. The written directive was for three fractions of 500 cGy for a total of 1,500 cGy. Then during the delivery of the second fraction the licensee realized that they were only delivering a planned dose of 166 cGy. The licensee completed the second fraction as planned. The treatment planning was entered as one third of the 500 cGy for three fractions instead of three fractions of 500 cGy. The license will modify the treatment plan to give the full prescribed 1500 cGy to the patient. The patient was notified on Jan. 27, 2014. This is a reportable medical event under OAC 3701:1-58-101 (A)(1)(c.) for a fractionated dose that differs by more than 50%. Ohio Report #: OH140001 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. |