The U.S. Nuclear Regulatory Commission issued two “event notices” earlier this year regarding incidents involving the Radiation Oncology Department at Salem Hospital.
One involved hospital personnel and the other involved a patient. No injuries have been reported so far, according to the Statesman Journal.
Salem Health volunteered to report both incidents, according to hospital spokesperson Lisa Wood. said Erica Hartquist, a spokesperson for the Oregon Department of Health investigating the incident.
The agency’s Radiation Protection Service licenses and monitors radioactive materials in the state. Hartquist said the OHA was unable to provide further information as the event is still under investigation.
“This kind of event is rare,” she said.
On March 22, a sealed source of Iridium-192 was delivered to the wrong floor of the hospital by a common carrier, according to NRC notification letters. This part is used by HDR devices.
Instead of being delivered to radiation oncology, it was delivered to a medical practice that rents space in the building.
“A person receiving a package without radiation safety or transport training signed it without understanding what it was and placed it on the floor of an access-controlled staff work area,” the notice said. has been written.
Salem Health did not realize the package had been delivered until March 28 when medical supplier Varian called them to schedule the installation of the quarterly delivery of parts.
“There was no indication on the licensee’s site to track the alternate source package in transit. This is under further investigation,” the NRC notice read.
“Salem Health was initially unaware of the delivery of the shipment and was unaware that it had been delivered to the wrong address,” said Wood. “Once the cargo’s location was discovered, Salem Health retrieved it and transferred it to a safe location.”
Salem Heath used survey meters to take radiation dosimetry measurements on and near the source package at various distances and orientations.
“It was determined that there would be no harm to patients or staff from this source issue,” Wood said.
On June 29, radiation oncology staff identified a deviation in the length of the transfer tube used to deliver the radiation.
“The tube was found to be 2.9 centimeters longer than the vendor’s specifications,” the NRC notice states.
“The treatment is therefore 2.9 centimeters shorter than the distance programmed for treatment, and includes 1.5 to 2 centimeters of unintended tissue…” he continues.
The transfer tube was last measured on July 27th, 2020. According to the NRC notice, Salem Health believes some patients may have received lower doses.
The hospital has identified two treatments where this could be the case and is compiling a list of all cases since the last tube measurement in 2020, the notice said.