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.