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The following was received from the state … The following was received from the state of Oregon via email:</br>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.</br>Oregon Report ID Number: 22-0031</br>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.necessarily result in harm to the patient. +
07:00:00, 29 June 2022 +
55,980 +
16:03:00, 7 July 2022 +
07:00:00, 29 June 2022 +
The following was received from the state … The following was received from the state of Oregon via email:</br>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.</br>Oregon Report ID Number: 22-0031</br>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.necessarily result in harm to the patient. +
Has query"Has query" is a predefined property that represents meta information (in form of a <a rel="nofollow" class="external text" href="https://www.semantic-mediawiki.org/wiki/Subobject">subobject</a>) about individual queries and is provided by <a rel="nofollow" class="external text" href="https://www.semantic-mediawiki.org/wiki/Help:Special_properties">Semantic MediaWiki</a>.
00:00:00, 7 July 2022 +
ORE-91006 +
Modification date"Modification date" is a predefined property that corresponds to the date of the last modification of a subject and is provided by <a rel="nofollow" class="external text" href="https://www.semantic-mediawiki.org/wiki/Help:Special_properties">Semantic MediaWiki</a>.
11:30:05, 15 July 2022 +
16:03:00, 7 July 2022 +
8.377 d (201.05 hours, 1.197 weeks, 0.275 months) +
07:00:00, 29 June 2022 +
URL"URL" is a <a href="/Special:Types/URL" title="Special:Types/URL">type</a> and predefined property provided by <a rel="nofollow" class="external text" href="https://www.semantic-mediawiki.org/wiki/Help:Special_properties">Semantic MediaWiki</a> to represent URI/URL values.