Interventional Radiology: ASN gives a level 2 rating on the Ines scale to an event in which the annual dose for a health care professional was exceeded in Saint-Eloi Hospital (Montpellier – Hérault regional university hospital)

On 30^th May 2013, ASN was informed that the passive dosimeter results for a radiation therapy technician in Saint-Eloi hospital of the Montpellier CHRU had integrated over the last quarter of 2012 an effective dose of 32 mSv. This result is higher than the regulation annual limit set at 20 millisieverts.

The hospital initially assumed malfunctioning or incorrect use of the dosimeter. Upon receipt of the incident notification, ASN then asked the hospital to investigate further and to report on the occupational physician’s conclusions.

Following receipt of the event report in November 2013, ASN carried out an inspection of the department on November 6^th, in order to more closely examine the circumstances in which this event occurred and conduct an on-site investigation of the radiation protection organisation.

The analysis carried out by the dosimeter supplier and the investigations conducted by the competent person in radiation protection and the occupational physician at the hospital, concluded that the interventional radiology procedures¹ alone were liable to explain the dose recorded.

The occupational physician declared the worker in question to be unfit for further exposure to ionising radiation and the person was no longer assigned to work exposing him to ionising radiation for a period of 12 months following the exposure, while at the same time benefiting from medical supervision.

During its inspection on 6th November 2013, ASN brought to light radiation protection shortcomings, particularly within the hospital’s operating theatre area. ASN requested improvements, especially concerning the actual wearing of dosimeters by workers in the operating theater, along with radiation protection training. These corrective actions demands appear in the inspection follow-up letter, accessible on the ASN website. ASN will be particularly vigilant with regard to the right implementation of these measures.

Owing to the annual dose for a worker being exceeded and failings in radiation protection culture, ASN rates this incident level 2 on the INES scale, graded from 0 to 7 by increasing order of severity of the incident.

1. Interventional radiology comprises medical procedures consisting of diagnostic or therapeutic interventions guided by medical imaging techniques involving X-rays.