Home Radiation 2 radiological incidents were investigated at Salem Health

2 radiological incidents were investigated at Salem Health

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The United States Nuclear Regulatory Commission issued two “event notifications” for incidents involving Salem Hospital’s radiation oncology department earlier this year.

One incident involved hospital employees, while the other involved patients. Investigations to date have revealed no injuries, the Statesman Journal reported.

Salem Health voluntarily reported both incidents, hospital spokeswoman Lisa Wood said. Both involved a cancer treatment device called a high dose rate, or HDR, afterloader, said Erica Heartquist, spokeswoman for the Oregon Health Authority, which is investigating the incidents.

A file photo of the Salem Health complex, Salem, Oregon, January 27, 2022.

Kristyna Wentz-Graff/OPB

The agency’s radiation protection services license and monitor radioactive materials in the state. The OHA was unable to provide more information as the events are still under investigation, Heartquist said.

“These kinds of events are rare,” she said.

On March 22, a sealed source of Iridium-192 was delivered by common carrier to the wrong floor of the hospital, according to the NRC notification document. The part is used in HDR device.

Instead of being delivered to radiation oncology, it was delivered to a medical office that rents space in the building.

“The person receiving the package, who has no training in radiation protection or transport, signed it without understanding or what it was about and placed it on the floor of a staff work area. controlled access,” the notification read.

Salem Health didn’t realize the package had been delivered until March 28, when medical provider Varian called to schedule installation of the part, which is delivered quarterly.

“There was no indication of tracking a replacement source package while it is in transit to the licensee’s site. This is under further investigation,” the NRC notification read.

“Salem Health was initially unaware of the delivery of the shipment and that it had been misdirected,” Wood said. “After discovering the location of the shipment, Salem Health retrieved the shipment and transferred it to its secure location.”

Salem Heath performed radiation dose measurements on and near the source package at various distances and orientations with a survey meter.

“It is determined that there was no harm to patients or staff from this source delivery issue,” Wood said.

On June 29, radiation oncology staff identified a discrepancy in the length of a transfer tube used to administer radiation.

“The tube was found to be 2.9 centimeters longer than the supplier’s specifications,” the NRC notification reads.

“The treatments will therefore be 2.9 centimeters shorter than the distance programmed for the treatments and will involve 1.5 to 2 centimeters of unplanned tissue…”, he continues.

The transfer tube was last measured on July 27, 2020. Salem Health believes it underdosed some patients, according to the NRC notification.

The hospital has identified two treatments where this may be the case and is listing all cases since the tube was last measured in 2020, the notification said.