[ RadSafe ] lessons learned (was: Radiography Incident)
Clayton J Bradt
CJB01 at health.state.ny.us
Wed Apr 4 13:06:27 CDT 2012
""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
NYS Dept. of Health
Biggs Laboratory, Room D486A
Empire State Plaza
Albany, NY 12201-0509
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