SALEM, Ore. — The U.S. Nuclear Regulatory Commission has 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 shown no injuries, the Statesman Journal reported.
Salem Health voluntarily reported both incidents, hospital spokesperson Lisa Wood said. Both involved a cancer therapy device called high dose-rate afterloader, or HDR, said Erica Heartquist, a spokesperson for the Oregon Health Authority, which is investigating the incidents.
The agency’s Radiation Protection Services licenses and monitors radioactive materials in the state. OHA was unable to provide further information because the events are still are 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’s notification document. The part is used in the HDR device.
Instead of being delivered to radiation oncology, it was delivered to a medical practice that rents space in the building.
“The person receiving the package, who does not have radiation safety or transportation training, signed for it without an understanding or what it was and placed it on the floor of an access-controlled staff working area,” the notification reads.
Salem Health did not realize the package had been delivered until March 28, when medical supplier Varian called to schedule installation of the part, which is delivered quarterly.
“There was no indication given of tracking a replacement source package while it is in transit to the licensee’s site. This is being investigated further,” the NRC notification reads.
“Salem Health was initially unaware of the shipment delivery and that it had been misdirected,” Wood said. “Upon discovering the location of the shipment, Salem Health retrieved the shipment and transferred 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 deviation in the length of a transfer tube used to deliver radiation.
“The tube was found to be 2.9 centimeters longer than the vendor’s specifications,” the NRC notification reads.
“Treatments therefore will be 2.9 centimeters shorter than the programmed distance for treatments and involving 1.5-2 centimeters of unintended tissue…” it continues.
The transfer tube had last been measured on July 27, 2020. Salem Health believes they may have underdosed some patients, according to the NRC notification.
The hospital has identified two treatments where this may be the case and is putting together a list of all cases since the last tube measurement in 2020, the notification says.
