Semantic search
Jump to navigation
Jump to search
| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 43091 | 1 December 2006 05:00:00 | Agreement State | Agreement State - Ohio - Equipment Malfunction of a Cobalt Teletherapy Device | On January 2, 2007, Ohio Bureau of Radiation Protection received a written report that an equipment failure of a Cobalt Teletherapy Device had occurred on December 1st while treating a patient. The sealed source did not return to the closed positron after completing treatment. The therapists immediately entered the room and returned the source to a safe configuration. The department requested additional information from the licensee on January 2 and received the additional information on January 9, 2007. It has been determined that the licensee did not perform a 24 hour notification as required in rule 3701-40-20 of the Administrative Code. The patient was exposed to less that thirty seconds exposure time and a determination was made from the additional information provided that a medical event did not occur. The unit was repaired by Neutron Products on December 8, 2006. The problem identified was an old air cylinder and detent pin which was replaced returning the unit to normal operation. The Department notified the NRC Operations Center on January 11, 2007 after determination of reporting requirements. Teletherapy unit is a Theratron-80, s/n 2640986, which is manufactured by Neutron Products. The Co-60 sealed source is 1690 Ci or 62530 GBq, model number NPTY, s/n T-1444. | ||
| ENS 46306 | 6 February 2008 04:00:00 | Agreement State | Agreement State Report - Medical Underdose During Prostate Brachytherapy | The following report was received via e-mail: The following report details "three Ohio Event Reports for two unreported medical events in 2008 (OH100022 and OH100023) and one unreported medical event in 2009 (OH100024). These events were discovered as a result of a special inspection conducted by ODH on 9/10/2010. Ohio Report Number OH100022: "An unreported medical event occurred at Clinton Memorial Hospital in Wilmington, Ohio on 2/6/08. On that date the licensee performed a prostate seed implant with I-125 seeds prescribed to deliver a dose of 144 Gray to the prostate. Post implant dosimetry showed that the received dose was >20 % below the prescribed dose." (The actual dose delivered was 97.5 Gray) Ohio Report Number OH100023: "An unreported medical event occurred at Clinton Memorial Hospital in Wilmington, Ohio on 3/21/08. On that date the licensee performed a prostate seed implant with I-125 seeds prescribed to deliver a dose of 145 Gray to the prostate. Post implant dosimetry showed that the received dose was >20 % below the prescribed dose." (The actual dose delivered was 102.5 Gray) Ohio Report Number OH100024: "An unreported medical event occurred at Clinton Memorial Hospital in Wilmington, Ohio on 5/20/09. On that date the licensee performed a prostate seed implant with I-125 seeds prescribed to deliver a dose of 144 Gray to the prostate. Post implant dosimetry showed that the received dose was >20 % below the prescribed dose." (The actual dose delivered was 107.5 Gray) 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. |