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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 55424 | 21 August 2021 20:00:00 | Agreement State | Prescribed Dose Exceeded | The following is a summary of information received from the State of Oregon: Licensee miscalculated and administered more radiation to a patient's spine than the prescription allowed. Radiation dose to the patient was intended to be 800 centigray but the actual dose delivered exceeded this by 21%. Oregon Emergency Response System Incident Number: 2021-2250 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.
The following is a synopsis of information received via e-mail from the state of Oregon via e-mail: After obtaining direct information from the responsible party, the radiation dose above the prescribed 800 centigray was from an x-ray generating device and is therefore a nonreportable event to NRC but is being investigated at the State (Oregon) level. This is not a reportable event to the NRC. Notified R4DO (KOZAL) and NMSS Events (by email). | ||
| ENS 53088 | 17 November 2017 08:00:00 | Agreement State | Agreement State Report - Medical Underdose | Eye plaque brachytherapy was being performed using I-125 seeds with a prescribed dose of 85 Gray. After the dose, the Iso-dose curve was noted to be different from the brachytherapy plan i.e. the dose was deeper than expected. Investigation revealed that a new model plaque was used which differed from the previous model. This resulted in an underdose with 65 Gray actually administered. Oregon Report: 17-0073 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 50991 | 15 April 2015 07:00:00 | Agreement State | Agreement State Report - Source Moved During Medical Treatment | On 4-15-15 the patient was to receive a fractionated dose of 4 Grays to the 'vaginal cuff' region using a 10.175 Curie Ir-192 source. The dose was to be administered using a Varian Model VariSource 200t remote HDR (High Dose Rate) afterloader, serial number 600349. The plan was to administer 6 radiation treatments using a cylinder applicator and holder, the treatment length intended to be 5 cm. Imaging was done after placement of the cylinder prior to treatment to verify location, however, post-treatment imaging showed that the cylinder applicator had come loose from the holder and shifted 3 cm. This was the first of the six fractions. Hospital staff physicists are currently working to determine the delivered dose to the target and why the shift occurred. Physician notification has not been verified at this time. The patient has been notified. 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 50554 | 17 October 2014 07:00:00 | Agreement State | Agreement State Report - Medical Misadministration | The following information was received via email: This is the initial notification that, on Friday, October 17th in Nuclear Medicine at OHSU (Oregon Health and Science University), a patient who was supposed to receive 25 mCi Tc-99m Sestamibi for a parathyroid scan was injected with 25.9 mCi of Tc-99m MDP, a bone scanning agent. The patient was notified, as was the referring physician. The patient was accompanied to meet with the referring physician. At this time, the exam will not be rescheduled. Investigation with the injecting technologist still in progress, and a letter will be sent to the patient. Radiation protection services will follow up with additional information. Oregon Incident Number: 14-0040 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. |