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Radiation Medical Events
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For the purposes of this reporting system, the Conference of Radiation Program Directors (CRCPD) has defined the following reporting criteria for a Radiation Medical Event.  A medical event indicates that a facility had technical or quality assurance problems in administering the physician’s orders.  There is no scientific basis to conclude that such a medical event necessarily results in harm to the patient  These events indicate a potential problem in a medical facility’s use of radiation.  Radiation Medical Events are separated into two sources: Therapy and Diagnostic. 

Other than events that result from intervention by a patient or human research subject, any event shall be reported in which the administration of ionizing radiation from a:

 Therapeutic radiation machine:
  • Involves the wrong patient, wrong treatment modality, or wrong treatment site; or
  • For which, the weekly administered dose differs from the weekly prescribed dose by more than thirty percent (30%); or
  • For which, the total administered dose differs from the total prescribed dose by more than twenty percent (20%) of the total prescribed dose; or
  • For which, the dose differs by fifty percent (50%) or greater for any single fraction of a multi-fraction treatment; or
  • Any equipment failure, personnel error, accident, mishap or other unusual occurrence that causes or is likely to cause significant physical harm to the patient

Diagnostic radiation machine:

  • Results in an unintended dose to the skin greater than 2 Gy (200 rads) to the same area for a procedure or series; or
  • Results in an unintended dose greater than 5 times the facility’s established protocol for a procedure and exceeds 0.5 Gy (50 rads) to an organ or 0.05 Gy (5 rads) total effective dose; or
  • Involves the wrong patient or wrong site for the entire diagnostic exam (procedure/service) and exceeds 0.5 Gy (50 rads) to an organ or 0.05 Gy (5 rads) total effective dose* for the procedure ; or
  • Involves any equipment failure, personnel error, accident, mishap or other unusual occurrence with the administration of ionizing radiation that exceeds 0.05 Gy (5 rads) total effective dose.

* Any wrong patient or wrong site imaged regardless of dose received should be reported, documented, and addressed internally within the facility.

Radiation Medical Events

Item Name Posted By Date Posted
H38 therapy Form Rev 2012.pdf PDF (297.12 KB) Administration 8/11/2016
Therapy Form Instructions.pdf PDF (190.21 KB) Administration 8/11/2016
H38 diagnostic Form 2012.pdf PDF (129.78 KB) Administration 8/11/2016
X-ray Form Instructions.pdf PDF (188.32 KB) Administration 8/11/2016

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