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Significant radiation protection events
concerning radioactive sources, waste and effluents
(6% of notified ESRs)
These ESRs are associated with the loss of radioactive
sources or the dispersion of radionuclides (leaks of
radioactive effluents from pipes or tanks, blocking of
pipes, uncontrolleddischarge of effluents into the collective
sewerage network, removal of waste to an inappropriate
disposal route). The number of ESRs notified dropped
verymarkedly in 2015 with 28 ESRs notified compared
with 47 in 2014. Despite the feedback from ASN to all
the nuclear medicine units in 2009 and 2012, events
concerning radioactive effluent leaks fromnuclearmedicine
units are still observed. They are linked to deficiencies
in the maintenance and monitoring of facilities that are
becoming obsolete.
In 2015, ASN rated 2 events concerning losses of sources
as level 1 on the INES scale on account of a safety culture
deficiency.
Medical exposure of women unaware of
their pregnancy (20% of the ESRs notified)
The notifications made to ASN concern exposure of the
foetus in women who were unaware of their pregnancy
when they underwent a medical imaging examination
(radiology and nuclear medicine). For the radiology
events notified in 2015, the doses received were without
expected consequences for the foetus or the child after
birth (ICRP, 2007). Further to the notification of several
events in nuclear medicine, the SFMN has, at ASN’s
request, updated its recommendations concerning
measures to detect pregnancy in women of child-
bearing age.
The analysis of these notifications rarely reveals
deficiencies in the information given to the women prior
to the examination when making their appointment,
immediately before the examination and via posters in
the changing booths. These notifications represent 99%
of the notifications made under the “public” criterion.
Synthesis of the significant radiation protection
events notified in 2015
The events notified to ASN in 2015 show that the most
significant consequences from the radiation protection
aspect concern:
•
forworkers: nuclearmedicine (contaminationof workers,
external exposure) and interventional radiology (external
exposure of operators and, in particular, exposure of the
extremities) although it is difficult to have exhaustive
knowledge of these situations because the wearing
of dosimeters is not common among interventional
practitioners;
•
for patients: interventional radiologywith deterministic
effects observed in patients having undergone long
and complex procedures, radiotherapy - particularly
for hypofractionated treatments, and lastly nuclear
medicine, radiopharmaceutical administration errors
for cohorts of patients;
•
for the public and the environment, nuclear medicine,
with leaks from pipes and radioactive effluent
containment systems.
The analyses of the ESRs notified to ASN once again
underline the need to increase the involvement of Persons
Competent in Radiation protection (PCR) and medical
physicists in themanagement of radiation protection, to
develop training of the professionals who use ionising
radiation, to implement procedures for quality and
safetymanagement and for the evaluation of professional
practices.
The experience feedbackmeasures included the issuance
of two periodic radiotherapy information bulletins based
on the capitalisation of the notified ESRs (more than
2,000 incidents in radiotherapy since 2007), produced
by radiotherapy professionals and ASN (bulletins No. 7
Regional University Hospital Centre of Lille.
Inversion of two patients receiving Gamma
Knife® treatment
Due to the inversion of two patients who were each to be
treated with a single radiotherapy session, one of the patients
was treated with the treatment parameters defined for
the other patient and vice versa. The first patient received
the entire dose planned for the second patient; the second
patient’s treatment session was interrupted when the
personnel noticed the error on returning the first patient to
their hospital room.
ASN’s investigations, carried out during the two inspections
of 9th January and 2nd March 2015, revealed that
the immediate causes resulted firstly from the lack of a
verification of the identity of each of the patients before
starting their treatment, and secondly the lack of a schedule
indicating the order in which the patients were to be taken,
even though the patients were waiting for their treatment at
the same time in the same waiting room. The root causes are
due to a poorly managed organisational environment (late
starting of treatments, task interruptions due to technical
problems, constraints in access to imaging, etc.),and all this
in a context of high workload. Although corrective measures
have been taken, such as putting in place a check-list in
which double-checking of the patient’s identity is formalised
and tracked, formalising the organisation for determining
the order in which patients are taken, and revising patient
routing, ASN considers that improvements are necessary,
particularly in the management of patient routing and in
redefining the responsibilities at each stage of the treatment
process.
TO BE NOTED
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CHAPTER 09:
MEDICAL USES OF IONISING RADIATION
ASN report on the state of nuclear safety and radiation protection in France in 2015