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The United States Nuclear Regulatory Commission issued two “incident notices” earlier this year for incidents involving Salem Hospital’s radiation oncology unit.
One incident involved hospital staff and the other involved patients. Investigations so far have not shown any damage, the Statesman Journal reported.
Hospital spokeswoman Lisa Wood said Salem Health voluntarily reported both incidents. Both involved a cancer treatment device called a high-dose-rate afterloader, or HDR, said Erica Hartquist, a spokeswoman for the Oregon Health Authority.
Salem Health Complex, Salem, Oregon, Jan. 27, 2022 file photo.
Kristyna Wentz-Graff / OPB
The agency’s Radiation Protection Service licenses and monitors radioactive materials in the region. OHA could not provide additional information because the incidents are still under investigation, Heartquist said.
“These types of incidents are rare,” she said.
According to the NRC notification document, on March 22, a sealed source of iridium-192 was delivered to the wrong floor of the hospital by a common carrier. The unit is used in the HDR tool.
Instead of being dedicated to radiation oncology, it was given to a medical practice that rents space in the building.
“The person who received the package, without radiation safety or transport training, signed for it or what it was and placed it on the floor of an access-controlled employee workstation,” the notice reads.
Salem Health didn’t realize the package had arrived until March 28, when medical provider Varian called to make an appointment to install the unit for its quarterly delivery.
“There was no indication of tracking during the transfer of the alternate source package to the permit area. This is being investigated further,” reads the NRC notice.
“Salem Health was initially unaware of the shipment and misdirected,” Wood said. “When the location of the shipment was determined, Salem Health retrieved the shipment and moved it to a safe location.”
Salem Heath performed radiation dose measurements near the source package and at various distances and directions with a survey meter.
“It was determined that there was no harm to patients or staff from this supply issue,” Wood said.
On June 29, radiation oncology staff identified a discrepancy in the length of the delivery tube used to deliver radiation.
“The pipe is 2.9 centimeters longer than the supplier’s specification,” the NRC notice reads.
“Thus, treatments are 2.9 centimeters shorter than the intended distance for treatments and include 1.5-2 centimeters of unintended tissue…” he continues.
The transmission line was last measured in 2011. It was July 27, 2020. According to the NRC notice, Salem Health believes some patients may not have overdosed.
The hospital has identified two treatments where this could happen and is compiling a list of all cases since the last tube measurement in 2020, the announcement said.
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