Semantic search
| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 56684 | 28 July 2023 04:00:00 | Agreement State | Treatment to Wrong Side of Organ | The following report was received via email by the Ohio Bureau of Radiation Protection: On July 28, 2023, a patient was scheduled to receive treatment to the right lobe of the liver, however, imaging performed on August 16, 2023 showed the left lobe received the dose. Approximately 83 mCi of Y-90 was delivered, resulting in a dose of 130 cGy (130 Rad) to the wrong treatment site. The patient and referring physician were notified. Future treatment of the left lobe of the liver was planned, but not under this written directive. Ohio Event Number: OH230009 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 56400 | 7 March 2023 05:00:00 | Agreement State | Misapplication of Medical Dose Resulting in Underdosing | The following information was provided by the Ohio Bureau of Environmental Health and Radiation Protection via email: Ohio State University reported a medical event on March 8, 2023. A written directive for 200 millicuries of lutetium-177 (PLUVICTO) to be administered intravenously was signed by an authorized user. The dosage was assayed at 195.57 millicures and was administered to the patient on March 7, 2023. During the administration, the Nuclear Medicine Technologist noted some drips from the tubing. An investigation was initiated and the results on March 8, 2023, indicate the patient received 157.57 millicuries of lutetium-177 (PLUVICTO), 21.5 percent less than the written directive. The investigation will continue to determine the root cause of the medical event and determine corrective actions if applicable. Reference Number OH 2023-006 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 55739 | 15 February 2022 13:00:00 | Non | Reportable Occurance Related to Building Exhaust Fan | The following information was provided by the licensee via fax or email: While performing the pre-start checkout on 2022-02-15 (at approximately 0800 EST), the SRO (Senior Reactor Operator) performing the checkout discovered that the building exhaust fan was not operating. This fan is required to be operating during reactor operations, and it is typically left running all the time. Troubleshooting determined that the cause of the fan loss was power loss from a conduit being cut the previous day when a small area of the cement floor in the janitor closet was being removed for replacement of the janitor closet sink. The concrete work was performed between 1200 and 1453 EST, which was when the contractor signed in and out. The reactor was shut down at 1551 EST, so the reactor was operated for at least an hour without the fan operating. There were no safety implications for the reactor, the staff, or the public. | ||
| ENS 55248 | 10 May 2021 05:00:00 | Agreement State | Dose to Improper Treatment Site | The following report was received from the state of Ohio via email: A patient was to receive a prescribed dose of 68.92 milliCuries Y-90 TheraSpheres to the left lobe of the liver on 5/10/2021. It was discovered during post treatment imaging on 5/11/2021 that the dose was delivered to the right lobe. The licensee stated the catheter position was verified prior to treatment and the cause of the event is under investigation. The referring physician and patient have been notified. Ohio Event Number: OH210003 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 54209 | 6 August 2019 04:00:00 | Agreement State | Agreement State Report - Leaking Eckert & Ziegler Cs-137 Vial Source | The following was report was received from the Ohio Department of Health via email: The licensee discovered a leaking Eckert & Ziegler Cs-137 vial source. The leak test result, performed on August 6, 2019, identified 0.016 microCuries of removable activity. Notification to the Ohio Department of Health was made on August 8, 2019. The licensee will dispose of the source through a licensed waste broker. Device model number: RV-137-250U Serial number: 171069 Ohio item number: OH190014 | ||
| ENS 45864 | 20 April 2010 04:00:00 | Agreement State | Agreement State Report - Possible Overexposure to a Member of the Public | Ohio Department of Health (ODH), Bureau of Radiation Protection (BPR) was notified of a possible overexposures to a member of the general public which occurred on 4/20/10 at the Ohio State University located in Columbus, Ohio. A patient received a temporary implant of Cs-137 and Ir-192 seeds on April 16-18, 2010. The patient's visitor (her fianc�) was instructed by the licensee that he could stay no longer than 2 hours with the patient in a twenty four hour period, and must stay behind the bedside shield during these visitations. On Tuesday, April 20, 2010, the licensee was informed by the Assistant Nurse Manager that the fianc� spent the night in the patient's room on two consecutive nights. In addition, the initial investigation by the licensee indicates that the visitor told the Assistant Nurse Manager that he slept in the same bed with the patient both nights. Nursing Management personnel are in the process of interviewing staff members that were involved directly with the care of the implant patient to verify that the fianc� was in the room overnight with the patient. A preliminary and conservative worst case dose estimate for the visitor is 6 Rad (6 cGy) whole body exposure, based on a 16-hour stay time (8 hours each night for two nights). ODH BRP will continue to collect information of this event and conduct an investigation. The licensee has initiated an internal investigation. Ohio Report OH100005
After investigation by the licensee and ODH the revised calculations indicate a dose estimate to the visitor to be 1.25 Rem. The licensee has instituted major procedural changes and conducted training for medical staff involved with brachytherapy treatments. |