RADIATION SAFETY POLICY

Transcription

1 RADIATION SAFETY POLICY Version Control Date Version No: 1 Implementation Date September 2005 Last Review Date September 2006 Next Formal Review Date September 2009 Version No: 2 June 2009 Next Formal Review Date June 2010 Version No: 3 Implementation Date Feb 2011 Last Review Date Jan 2011 Next Formal Review Date Jan 2014 EQIA Date Version No: 1 August 2009 Approval Record Date Shetland NHS Board September 2005 Shetland NHS Board August 2009 Shetland NHS Board Feb 2011 Storage Location SHB Documents Intranet site Page: Page 1 of 11

2 NHS Shetland s Accessible Information Policy To get this information in another language or format please phone NHS Shetland on Albanian Për ta marrë këtë informacion në një gjuhë ose në një format tjetër, ju lutemi telefononi te NHS Shetland në numrin Arabic Bengali NHS - ৷ Cantonese NHS Shetland 如需以其他語言或格式獲得此資訊, 敬請致電 聯繫 NHS Shetland Croatian Za dobivanje ovih informacija na nekom drugom jeziku ili u drugom formatu, molimo nazovite broj NHS Shetlanda Czech Chcete-li obdržet tuto informaci v jiném jazyce nebo formátu, volejte, prosím, NHS Shetland na Farsi NHS Shetland Korean 다른언어나형식으로정보를받으려면국민건강보험셰틀랜드 (NHS Shetland) 번으로전화해주시기바랍니다. Lithuanian Norėdami gauti šią informaciją kita kalba ar formatu, skambinkite NHS Shetland telefonu Mandarin 如如如如如语如如如如语如如如如, 敬请敬请 联系 NHS Shetland Polish W celu uzyskania tej informacji w innym języku lub formacie proszę skontaktować się z NHS Shetland pod numerem telefonu: Portuguese Para obter esta informação em outro idioma ou formato deve telefonar para NHS Shetland, tel Punjabi ÇÂà ÜÅäÕÅðÆ ù çèãðæ íåôå Ü» øåðîëà Çò¼Ú êåà ä ñâæ ÇÕðêÅ ÕðÕ Óå NHS ô àñëºâ ù ø é Õð Í Romanian Pentru a obţine aceste informaţii în alte limbi sau în alt format, contactaţi NHS Shetland la numărul de telefon Storage Location SHB Documents Intranet site Page: Page 2 of 11

3 RADIATION SAFETY POLICY STATEMENT NHS Shetland will ensure, as far as is reasonably practicable, the health and safety of members of the public, of its employees and of contractors working on the premises who may be exposed to the hazards arising from the use of ionising radiation, lasers, radiofrequency and microwave radiations, ultra-violet radiation and other optical radiation sources. NHS Shetland is committed to a policy of keeping exposures to ionising and non-ionising radiations as low as reasonably practicable. NHS Shetland must appoint a Radiation Protection Adviser (RPA) to advise on compliance with the relevant legislation and implementation of safety requirements concerning the use of ionising and non-ionising radiations respectively. A Medical Physics Expert (MPE) will be provided through the Radiation Protection Service who can be consulted for advice on all matters relating to dose optimisation and radiation protection. Radiation Protection Supervisors (RPS) will be appointed in appropriate departments to enable work with radiation to be carried out in a safe manner. All radiation facilities will be designed to meet requirements of relevant current regulations and supporting documentation to ensure that doses to members of the public, patients and employees are below any relevant dose constraints. Local Rules will be prepared to cover all procedures using ionising radiation and areas where hazardous exposure to nonionising radiations could occur. Radiation doses to all staff working with ionising radiation will be monitored by means of whole body dosemeters, extremity dosemeters and/or environmental monitoring, as deemed appropriate by the RPA. The minimising of radiation doses to patients will be a prime factor taken into consideration in the selection of X-ray equipment. Quality Assurance tests will be carried out at regular intervals on all equipment involved in patient exposure with ionising radiation, as required by current legislation. All staff working with ionising and non-ionising radiation will be given training to enable them to carry out their duties safely and in line with current legislation. Note: NHS Shetland Provision for the implementation of the Ionising Radiation (Medical Exposure) Regulations 2000 are described in a separate policy document entitled NHS Shetland Policy on the Implementation of the Ionising Radiation (Medical Exposure) Regulations 2000 Storage Location SHB Documents Intranet site Page: Page 3 of 11

4 1. Persons Responsible for Implementation of the Policy NHS Shetland is committed to a policy of restricting exposures to ionising and non-ionising radiations and will effect this through the following organisational arrangement and responsibilities. Overall responsibility for the safe use of ionising and non-ionising radiations within NHS Shetland lies with the Chief Executive Officer. The Chief Adminstrative Medical Officer (CAMO) is responsible to the Chief Executive Officer for all matters related to the safe use of ionising and non-ionising radiations withing NHS Shetland. NHS Shetland will appoint a Radiation Protection Adviser (RPA), with appropriate experience and qualifications, to advise on all matters concerning the use of ionising radiations. (See Appendix 1.) NHS Shetland will notify this appointment to the HSE. NHS Shetland will have a Radiation chaired by the CAMO / Director of Public Health and attended by the RPA. This committee oversees the management of Radiation Safety within NHS Shetland and assists NHS Shetland in fulfilling all its legal obligations in this work. In addition to the Chief Adminstrative Medical Officer and RPA, the Radiation will consist of Managers and RPS s from departments where ionising and non-ionising radiations are used. This committee will meet at least once every six months. The committee is responsible for: Reviewing the radiation protection arrangements in NHS Shetland. Reviewing and auditing compliance with Ionising Radiation Regulations 1999 (IRR99) and the Ionising Medical Exposure regulations 2000 (IR(ME)R2000). Reviewing Laser safety arrangements. Promoting a culture of radiation safety within NHS Shetland. Reviewing the auditing of quality assurance programmes in NHS Shetland. Receiving guidance from the RPA /MPE on radiation matters. Reviewing and when necessary acting upon the findings of investigations into radiation incidents 1.1. Ionising Radiation The Radiation Protection Service (appendix 1) is responsible to Shetland NHS Board, under contract, for provision of an advisory service; quality assurance and dose monitoring programmes. The MPE from this service will be available for consultation Storage Location SHB Documents Intranet site Page: Page 4 of 11

5 on optimisation, including patient dosimetry and quality assurance, and to give advice on matters relating to radiation protection. A Report on the work of the Radiation Protection Service will be submitted annually to the Radiation. The Head of Medical imaging or the Senior Dental Officer with the advice of the RPA are responsible to Shetland NHS Board for ensuring compliance with IRR99 with their departments. This will include ensuring suitable risk assessments are carried out, local rules are produced for all radiation controlled and supervised areas, for issuing personal radiation monitors and consulting the RPA on matters of compliance. Responsibility for supervising the work with radiation and ensuring that it is done in accordance with Local Rules will lie with Radiation Protection Supervisors (RPSs) appointed in writing by the Board. (See Appendix 1.) Responsibility for maintaining an inventory of ionising radiation equipment, and for ensuring that all such equipment both satisfies radiation safety requirements and is subject to an appropriate replacement programme will rest with the Head of Medical Imaging or the Dental Officer. (See Appendix 1.) It is the responsibility of every Board employee working with ionising radiation to be aware of the Local Rules and precautions necessary to carry out their work in a safe manner. It is their responsibility not to expose themselves or any other person to ionising radiation to a greater extent than is reasonably necessary for the purpose of their work. NHS Shetland must consult the RPA on the following matters:- The implementation of requirements as to controlled and supervised areas. The prior examination of plans for installations and the acceptance into service of new or modified sources of ionising radiation in relation to any engineering controls, design features, safety features and warning devices needed to restrict exposure to ionising radiation. The regular calibration of equipment provided for monitoring levels of ionising radiation and the regular checking that such equipment is serviceable and correctly used. The periodic examination and testing of engineering controls, design features and warning devices and regular checking of systems of work provided to restrict exposure to ionising radiation. Prior risk assessments. Other matters related to compliance of IRR99. Storage Location SHB Documents Intranet site Page: Page 5 of 11

6 It must be noted that employees of other NHS Boards are involved in providing the radiology and dental services so it is important there is open dialogue between the different employers in order to promote radiation safety. 2. Procedures For Compliance With IRR Prior Risk Assessments A risk assessment should be carried out before any new work starts which involves ionising radiation. The risk assessment should be used as a tool for informing on the control measures which should be in place to ensure doses arising from the work are as low as reasonably practicable. For existing work risk assessments should be reviewed at least annually or when there are significant changes in workload or practice. The RPA should be involved in drawing up and reviewing risk assessments Design of Radiation Facilities The RPA will be involved in the planning of all new radiation facilities and any changes to existing facilities. All radiation facilities will be designed to meet requirements of current legislation, supporting documents and recommended guidance in force at the time to ensure that exposures to members of the public, other patients and staff are below any relevant dose constraints Operational Procedures and Local Rules Local Rules set out procedures designed to minimise radiation doses to staff, patients and members of the public. Local Rules will be prepared to cover all procedures using ionising radiation carried out in NHS Shetland and ones where hazardous exposure to non-ionising radiation could occur. The Local Rules include systems of work which must be followed at all times. Local Rules will be reviewed regularly by the RPS for each area and the RPA. New rules will be prepared whenever a new procedure, with radiation protection implications, is introduced or a new radiation facility is installed. It is the responsibility of the RPS to inform the RPA of any new procedures and to prepare Local Rules in consultation with the RPA and other relevant staff. The RPS for each area is responsible for ensuring that staff are made aware of changes in Local Rules. Contravention of Local Rules must be reported to the local RPS, and where necessary the RPA, and appropriate action taken. Significant contravention of Local Rules will be brought to the attention of the Radiation and will be a disciplinary offence. Storage Location SHB Documents Intranet site Page: Page 6 of 11

7 2.4. Radiation Doses to Staff NHS Shetland, via the Radiation Protection Service, will endeavour to maintain radiation doses to all staff working within the hospital at the lowest level practicable and will monitor this by means of whole body dosemeters, extremity dosemeters and/or environmental monitoring, as deemed appropriate by the RPA. Radiation doses to staff routinely using ionising radiation on a daily basis will be monitored regularly by the Radiation Protection Service. Periodic monitoring of other staff and of environmental doses in the workplace will be carried out in other areas where radiation is used, as deemed appropriate by the RPA. In addition, extremity doses will be continually measured for staff manipulating radioactive materials and monitored periodically for other staff, as considered necessary by the RPA. Doses to all staff will be assessed every two months by the RPA and by the local RPS. Whenever a staff member receives a body radiation dose ( effective dose ) greater than 0.3 msv over the monitor badge wear period, or 2.0 msv within one year, the RPS and RPA will investigate and implement changes as deemed necessary Arrangements for Pregnant Staff Working with Ionising Radiation Generally radiation protection measures are designed to ensure that doses received by all staff are as low as reasonably achievable. If all the procedures outlined in this document and the department local rules are followed, staff members should not receive any radiation above the minimum recordable limit for the personal dosemeter. However, employers are required to assess the risks to pregnant and breast feeding workers to ensure any risks are kept to the minimum. Each department will operate a policy to ensure that staff who become pregnant are not involved in any situation where a significant dose may be received and do not receive a radiation dose which approaches the dose limit to the foetus. These arrangements will depend on the staff involved and the options for rotation to different areas. Some staff may be required to work under a restricted schedule especially areas where there is a greater potential for radiation exposure. There may be a requirement for more vigorous monitoring of radiation dose to be undertaken where the RPA deems this appropriate. The dose limit to the foetus of a pregnant worker is 1 msv. In practice, for staff working with X-rays, this dose would be interpreted as a dose limit of 2 msv to the surface of the abdomen over the declared term of the pregnancy. A useful reference on this topic is "Pregnancy and Work in Diagnostic Imaging" by RCR and BIR (1992). This policy does not cover manual handling etc. which may also be a consideration when reviewing work. Storage Location SHB Documents Intranet site Page: Page 7 of 11

8 Diagnostic X-Ray Radiographers Radiographers who may be pregnant are at no added risk whilst carrying out radiographic duties, if they can protect themselves behind a lead screen (permanent or mobile) during the exposure. Radiographers who are or may be pregnant should inform the RPS so that doses received during the pregnancy may be totalled. If the total dose received by a pregnant radiographer reaches 0.5 msv, the RPA must be informed by the RPS. Pregnant radiographers may undertake ward and theatre radiography during the term of their pregnancy and be extra vigilant about following standard protection measures e.g.: 1. A lead rubber apron is worn or a mobile lead screen used, when available, for protection. 2. The radiographic exposure is made at the maximum extension of the exposure cable. 3. The beam is directed away from the staff member. 4. That careful choice of exposure factors is made to ensure the minimum chance of repeat examinations. Radiographers may decide whether they wish to discontinue routine participation in out of hours work during their pregnancy because of the physical demands of such work. If they do not wish to carry out routine out-of-hours work, they must contact the Head of Service so as to make alternative arrangements Radiation Protection Physicists and Technicians Following a declaration of pregnancy, the staff member involved must exercise increased awareness of their own radiation dose and how this can be minimised in procedures in which they are involved. A personal dose meter may be issued in order to provide an immediate indication of any radiation dose received Nursing Staff The policy for dose reduction for pregnant nursing staff is designed to ensure minimum risk to staff who may be pregnant. Measures are designed to ensure that doses received during pregnancy are as low as reasonably achievable. Nursing staff who are or may be pregnant should inform their line manager, who must arrange that the precautions, outlined in this document, be taken to restrict their radiation exposure. Storage Location SHB Documents Intranet site Page: Page 8 of 11

9 They will not be asked to accompany patients attending the X-ray Department for any examination in which they may be required to be present in the room during any radiation exposure Radiation Equipment and Quality Assurance Quality Assurance tests will be carried out at regular intervals on all equipment involved in patient exposure with ionising radiation. Time scales will be within those required by current legislation and accompanying guidance. The MPE/RPA can be consulted for advice on all Quality Assurance issues. Any equipment or apparatus used in connection with medical exposures will, as far as reasonably practicable, be installed and maintained as to be capable of restricting the exposure of the patient to the extent compatible with the clinical purpose following HSE Guidance Note PM Selection and Acceptance of X-ray Equipment The minimising of radiation doses to patients will be a prime factor taken into consideration in the selection of new equipment. The RPA will be consulted and will advise regarding the selection and purchase of all diagnostic and therapeutic X-ray equipment. During the installation, an RPA will carry out a critical examination of all equipment capable of emitting ionising radiation before the equipment is used clinically. This requirement will be included in the contract drawn up with the suppliers of the equipment. NHS Shetland should have a programme for replacement of ageing equipment and identifying priorities for replacement Staff Training Staff working with ionising and non-ionising radiation will have appropriate training to perform their duties. All RPSs should either have attended an appropriate training course or attend one within six months of their appointment, and then attend updates as required. Radiation Protection training for other staff will be provided by the local RPS and/or Radiation Protection Service at appropriate intervals, in consultation with the local RPS. Appropriate training in correct use of new equipment will be given to all staff, where it is required. Storage Location SHB Documents Intranet site Page: Page 9 of 11

10 Training records must be kept in each department and signed off by the manager to show evidence of the basic qualification, induction training, basic training in radiation protection and equipment related training Radiation Protection Audit Radiation protection audits of all major departments using ionising radiations will be carried out annually by the RPA in consultation with the local RPS. Practices in minor installations will be reviewed at intervals considered appropriate by the RPA Incident Reporting All departments should have procedures in place for reporting incidents and near misses and use the incident reporting system where appropriate. In addition to this the Board has the responsibility to report certain incidents to the regulatory authorities. Further advice on reporting radiation incidents is contained in procedure EP5 and the IR(ME)R implementation policy. Abbreviations BIR British Institute of Radiology CAMO Chief Administrative Medical Officer DPH Director of Public Health HSE Health & Safety Executive IR(ME)R Ionising Radiation (Medical Exposure) Regulations 2000 IRR99 Ionising Radiation Regulations 1999 MPE Medical Physics Expert msv MilliSieverts: a measure of radiation RCR Royal College of Radiologists RPA Radiation Safety Advisor RPS Radiation Protection Supervisors Storage Location SHB Documents Intranet site Page: Page 10 of 11

11 Appendix 1 Shetland NHS Board Representative with Responsibility for Radiation Issues Chief Administrative Medical Officer Radiation Protection Adviser/Medical Physiscs Expert Head of Radiation Protection Service, Department of Bio-Medical Physics and Bio-Engineering, Aberdeen Royal Infirmary, Foresterhill, Aberdeen Radiation Chief Administrative Medical Officer (Chairman) Head of Service, Medical Imaging Department Radiation Protection Adviser Radiation Protection Supervisor(s) Chief Administrative Dental Officer Occupational Health Nurse Medical Director Director of Clinical Services Health and Safety Manager Radiation Protection Service Radiation Protection Service, Department of Bio-Medical Physics and Bio-Engineering, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, AB25 2ZD Tel: or ext Radiation Protection Supervisors Medical X-ray Facilities Appointed senior radiographers, Medical Imaging Department, Gilbert Bain Hospital, Lerwick. Tel: Dental X-ray Facilities The dentist in charge of each practice (excluding Independent Contractors) with Chief Administrative Dental Officer having overall responsibility as appropriate. Responsibility for Maintaining an Inventory of Radiation Equipment Head of Medical Imaging Department Chief Administrative Dental Officer Medical Imaging Equipment Dental Imaging Equipment Storage Location SHB Documents Intranet site Page: Page 11 of 11