[ RadSafe ] Radiography Incident

[Chris Alston]

Bill

Yes, it was many years ago, now.  The pt died, and maybe three dozen
other people got doses up to (as I best recall) 100 rem.

Basically, the folks at the clinic at which she was being treated
ignored a number of good, and even common sense, practices.  Maybe
most crucially, they knew that the area monitor in the treatment vault
was prone to false-positives ("crying wolf", as it were).  But, they
did not repair or replace it.  So, when they got a *true* positive
alarm, they ignored it.  They also did not wave a survey meter over
the pt, at any time (but, preferably, before bringing her out of the
vault).  I mean, ideally, what one does is to enter the room holding
the survey meter in front of one, so that, if the source, or part of
it, is not fully shielded within the machine, one knows immediately.
The use of a survey meter is now a religious rite, for everyone who
treats HDR.  I know of at least one site at which the nurses will not
enter the treatment room, unless Physics walks in ahead of them with a
survey meter, regardless of the readings on the area monitor.  And woe
betide the institution which, on inspection, is found to have a bad,
or even out-of-cal, survey meter for use with the HDR machine.

Cheers
cja


---------- Forwarded message ----------
From: William Lipton <doctorbill34 at gmail.com>
Date: Tue, Apr 3, 2012 at 9:57 PM
Subject: Re: [ RadSafe ] Radiography Incident
To: "The International Radiation Protection (Health Physics) Mailing
List" <radsafe at health.phys.iit.edu>


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

Bill Lipton
It's not about dose, it's about trust.