|Entered date||Site||Region||Reactor type||Event description|
|ENS 55248||11 May 2021 15:46:00||Ohio State University||NRC Region 3||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||8 August 2019 11:11:00||Ohio State University||NRC Region 3||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||21 April 2010 12:00:00||Ohio State University||NRC Region 3|
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.