[ RadSafe ] lessons learned (was: Radiography Incident)

[Clayton J Bradt]

""I read about one case in which an HDR patient was sent back to her 
nursing home with the source still in her!"

"That is true, it happened in a clinic in Pennsylvania in early 1990s. I 
worked for the same company, in a different clinic, after the event.

"However, the lesson learned from that event are enormous, and led to 
re-engineer the device." 



Bill & Ahmad:

The lessons learned from this incident were all the wrong ones. NRC 
claimed that the root cause of this patient's death was a design flaw in 
the in the way the source/wire combination were stored within a teflon 
coated container. The radiolysis of the teflon generated corrosive 
chemicals that attacked and weakened the wire.  NRC criticized the State 
of Louisiana's radiation program for missing this design flaw when it 
conducted its Sealed Source and Device review for the source. 

Of course the real cause of the patient's death was malfeasance by the 
licensee's personnel, the RSO and the NRC. 

1)The NRC had authorized the licensee to operate ten facilities with only 
one RSO. [This should never have been accepted by the NRC license 
reviewers. The RSO should either be on site or  available to respond 
immediately whenever treatments are being performed. This is impossible 
with ten facilities geographically scattered around the state.  The RSO is 
also responsible for ensuring licensee personnel are trained in and 
understand radiation safety procedures, but upon interviewing the 
employees at the Indiana, Pennsylvania facility (the site of the incident) 
it was learned that they didn't even know who the RSO was.] 

2)  The area radiation monitor, which did indicate that the source was 
still outside of its shield after treatment was finished, had a history of 
problems and instead of being repaired immediately it was simply assumed 
to be malfunctioning and ignored. [Area monitors should be operationally 
checked at the beginning of each day that treatment is to be performed. If 
not operational it should be fixed before treatment can be performed.]

3) No survey of the patient with a hand held instrument was performed to 
verify removal of the source from the patient. [This is to be a double 
check of the area monitor and the source position indicator on the HDR.]

 In the face of these glaring procedural failures, NRC chose to lay the 
blame at the feet of Louisiana's SS&D review!  Mechanical devices fail. 
Sources become disconnected. These are events that can be readily 
anticipated and procedures are supposed to be in place so that employees 
can detect and mitigate their effects. 


Clayton J. Bradt
Principal Radiophysicist
NYS Dept. of Health
Biggs Laboratory, Room D486A
Empire State Plaza
Albany, NY 12201-0509

518-474-1993