Event Notification Report for August 21, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/20/2021 - 08/21/2021
EVENT NUMBERS
55424
55424
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
Agreement State
Event Number: 55424
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: Oregon Health and Science University
Region: 4
City: Portland State: OR
County: Multnomah
License #: ORE-90013
Agreement: Y
Docket:
NRC Notified By: Daryl Leon
HQ OPS Officer: Mike Stafford
Licensee: Oregon Health and Science University
Region: 4
City: Portland State: OR
County: Multnomah
License #: ORE-90013
Agreement: Y
Docket:
NRC Notified By: Daryl Leon
HQ OPS Officer: Mike Stafford
Notification Date: 08/23/2021
Notification Time: 15:20 [ET]
Event Date: 08/21/2021
Event Time: 13:00 [PDT]
Last Update Date: 08/24/2021
Notification Time: 15:20 [ET]
Event Date: 08/21/2021
Event Time: 13:00 [PDT]
Last Update Date: 08/24/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
KOZAL, JASON (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
KOZAL, JASON (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 9/24/2021
EN Revision Text: AGREEMENT STATE REPORT - 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.
* * * RETRACTION ON 24 AUGUST 2021 AT 1550 EDT FROM DARYL LEON TO KAREN COTTON * * *
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).
EN Revision Text: AGREEMENT STATE REPORT - 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.
* * * RETRACTION ON 24 AUGUST 2021 AT 1550 EDT FROM DARYL LEON TO KAREN COTTON * * *
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).