Two mishaps at the Salem Hospital in Oregon have led to “event notifications” by the U.S. Nuclear Regulatory Commission.

The events took place earlier in 2022 and were self-reported by the hospital. One involved the misdelivery of a high dose-rate afterloader (HDR). The other episode involved the incorrect length of a transfer tube that may have led to some patients being underdosed.

To date no injuries from the episodes have been found.

Salem Health voluntarily reported both incidents, hospital spokesperson Lisa Wood said, according to the Salem Statesman Journal.

While the ongoing Oregon Health Authority investigation prevents further information at present, Erica Heartquist, a spokesperson, did note that, “these kinds of events are rare.”

The first situation took place March 22, when “a sealed source of Iridium-192 was delivered by common carrier to the wrong floor of the hospital,” according to the NRC’s event notification document. The part is used in the HDR device.

The package — from Varian — was intended for the radiation oncology department on the third floor, but instead wound up at a medical practice in the same building but on the fourth floor.

“The person receiving the package, who does not have radiation safety or transportation training, signed for it without an understanding of what it was, and placed it on the floor of an access-controlled staff working area,” the notification stated.

Only when Varian reached out to Salem Health on March 28 to schedule HDR installation, did the hospital realize the initial delivery had gone amiss.

“Salem Health was initially unaware of the shipment delivery and that it had been misdirected,” Wood noted to the Journal. “Upon discovering the location of the shipment, Salem Health retrieved the shipment and transferred to its secure location.”

According to the NRC notification, Salem Health evaluated the dose received by clinic staff working around the package.

No staffer worked a full shift in the area, and came no closer than 2 feet from it. The exposure period was 5 days before the mistake was uncovered. Dose measurements near the package suggested that “the maximum dose received was calculated to be 0.4 mR/hr,” according to the NRC report.

“It is determined that there was no harm to patients or staff from this source delivery issue,” Wood told the paper, adding that, “with process improvements in place, subsequent deliveries to Salem Health of the same material have been received without incident.”

The other issue came to light June 29, when radiation oncology staff determined a problem with the length of a transfer tube that was “2.9 centimeters longer than the vendor’s specifications,” according to the Associated Press.

This may have led to underdosing. Salem Health has, in fact, uncovered two such treatment shortfalls, on May 13 and June 22, “and is putting together a list of all cases since the last tube measurement in 2020,” according to AP.

“It would be premature to discuss this event, as Salem Health is investigating the change in the tube as well as the time frame,” Wood said. “While our investigation is still in process, our physicists have updated the safety protocol to ensure the tube is correctly sized before every treatment.”

Salem Hospital was last in the news in late July, remaining for over a year at 100% capacity, and forced to divert ambulances for the first time, according to the Journal.

“There are limits to our capacity, and we are addressing the root causes of high capacity through a number of tools,” Wood said, according to the paper.