Interventional Radiology: the exceeding of an annual dose limit by a health professional at the Val de Saône Polyclinic in Mâcon (Saône-et-Loire department) is rated level 2 on the INES scale by ASN
On 18th August 2014, ASN was informed by the Val de Saône Polyclinic in Mâcon (Saône-et-Loire department) that a private-sector surgeon working in the operating block had exceeded the regulatory annual whole body dose limit of 20 mSv.
The situation was discovered on reception of the results of the quarterly dosimetric monitoring of the practitioner concerned. The monitoring showed that the dose received by the practitioner reached 49.5 mSv for the 1st quarter of 2014, bringing the total dose received over the last twelve months to 65 mSv, whereas the regulatory limit is set at 20 mSv.
On 3rd September 2014, ASN conducted an inspection to determine the circumstances of this event in greater detail and to examine the radiation protection organisation in the polyclinic.
The analysis of the dosimetric results for the last twelve months revealed regularly high exposure values for the practitioner concerned. They result in particular from the failure to use the personal or collective protective equipment available to the practitioner when using radiology devices during surgical procedures, and the lack of optimisation of the doses delivered by the radiology devices.
The ASN inspection highlighted malfunctions in terms of radiation protection, particularly in the operating block: no overall coordination of the prevention measures taken by the polyclinic or by the private-sector surgeons and no organisation plan for medical radiation physics or optimisation of doses delivered to patients, plus the failure of several surgeons to wear active dosimeters (including the surgeon who exceeded the regulatory limit).
ASN noted these deviations from the regulations and requested corrective actions, which figure in the inspection follow-up letter accessible on the ASN website. It will monitor the implementation of these actions very closely.
Owing to the exceeding of an annual dose limit for a worker and the lack of radiation protection culture, ASN has rated this incident level 2 on the INES scale, which is graded from 0 to 7 in increasing order of severity.
ASN once again draws the attention of medical establishment directors and medical professionals to the serious potential consequences of deficient radiation protection for both workers and patients in the area of interventional radiology. It emphasises that 2 letters have already been sent to the services practising interventional radiology in 2009 ans 20141.
1. Circular letters available on the ASN website via the following link: http://professionnels.asn.fr/Activites-medicales/Radiologie-interventionnelle/Lettres-circulaires-en-radiologie-interventionnelle
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