Bordeaux University Hospital (CHU) – Pellegrin Hospital - Bordeaux - A practitioner’s regulatory annual exposure dose limit was exceeded ASN rates the event level 2 on the INES scale
On 14th October 2014, ASN was informed by Bordeaux CHU that the regulatory annual whole-body dose limit of 20 mSv was exceeded by an orthopaedic surgeon while using an interventional radiology device (image intensifier) in the operating theatre.
The event came to light when the practitioner’s passive dose monitoring results were received and showed that the dose received between June 2013 and June 2014 was 25 mSv.
The investigations carried out by the hospital were unable to identify the causes of this exposure and more specifically whether the practitioner was regularly using individual protection equipment. Furthermore, the surgeon’s failure to wear an operational dosimeter meant that the measurement results could not be compared with the passive dosimetry results.
ASN carried out an inspection on 1st December 2014 on the unit in which the event had taken place. This was the subject of a letter requesting corrective measures, in particular concerning the actual wearing of dosimeters by all the professionals concerned and the deployment of collective protection equipment.
A worker had already exceeded the regulatory dose limits in similar working conditions in 2009 and 2010 in the same hospital.
Consequently, owing to this further instance of a worker exceeding an annual dose limit and the lack of radiation protection culture, ASN rates this incident level 2 on the INES scale.
ASN would once again draw the attention of the hospital directors and professionals to the significant implications of radiation protection in the field of interventional radiology, both for the workers and the patients. It recalls that 2 letters were already sent out to the units carrying out interventional radiology, in 2009 and 2014.