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Therapy Accelerator Medical Events

The Radiation Safety Section (RSS) is providing the following summary information of medical events involving therapy accelerators in Michigan. Medical event information involving the use of radioactive materials is maintained by the U.S. Nuclear Regulatory Commission (NRC). An NRC Information Notice regarding medical events related to gamma stereotactic radiosurgery can be found on their website.

Currently there are 69 facilities in Michigan performing radiation therapy treatments using a total of 118 accelerators. The RSS does not track the total number of therapy treatments or patients. Until May 2012, the RSS required operators of therapy accelerators to report errors resulting in a total radiation dose differing by more than +/- 10% of the total prescribed dose or errors resulting in a radiation dose greater than 25% of the prescribed dose for any treatment fraction. These errors were termed "misadministrations".

Beginning in May 2012, new conditions for reporting of "medical events" went into effect:

Except for an event that results from patient intervention, the registrant shall report in writing within 30 days to the Department any event from the administration of therapeutic radiation that:

  • Results in the total dose delivered differing from the prescribed dose by 20% or more; or
  • Results in any single delivered fraction of a fractionated treatment exceeding the prescribed dose by 50% or more; or
  • Involves the wrong patient, wrong treatment modality, or wrong treatment site.

The following table shows the number of reported misadministrations/medical events since 2000 that met the criteria above. A summary of each event can be observed by clicking on the year in the following table. The RSS is providing this information in an easily accessible form for interested citizens of the state. The RSS believes that operators of therapy accelerators may also benefit from this information. No patient or facility information is provided

Year

Total Number of Medical Events

2000

3

2001

0

2002

5

2003

1

2004

3

2005

3

2006

5

2007

1

2008

3

2009

2

2010

1

2011

2

2012

3

2013

2

2014

7

Last Update: 10/15/2014





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