application for renewal of license 45-01291-03.fee paid
TRANSCRIPT
, -
g
'hk e* ?t ' Mff -.
Roanoke~ ~
MemorialHospitals
,Date: August 19, 1988 . A' Affiliate of CAIULION Health Systemn
U.S. Nuclear Regulatory Commission "Region III. .
.
$-Nuclear Materials Safety Section3101 Marietta Street,' Suite 2900 ,
Atlanta, Georgia 30323 CS"
Subject: Renewal Application Letter .E 'ca
Ref: Cobalt--60 Teletherapy Materials License #45-01291-03_
a.Gentlemen:
Roanoke Memorial Hospitals is hereby submitting a request for renewal'of ourpresent NRC By-Product Materials License-#45-01291-03.
Supportive information required in Appendix L-2. of " Guide for the Preparationof Applications for Licenses for Medical Teletherapy Programs" (2nd draft,previously issued as TM 608-4) is enclosed.
We have enclosed a check in the amount of $350 for the renewal of this licensein the category of by-product material: Paragraph 170.31(7.A)
Thank you for your continued help, and we remain at your disposal should youneed additional information or if there are concerns with regard to this
renewal. application. )
' Sincerely,
3-:-d . - - '
W. Andrew Dickinson, Jr. !
Senior Vice President* 95
ns _ _ -. :,
s
k i
pg a pe: U.S. NRC Document Management Branch ds ? j
g: ,i ,-
J
~cL ;
E08-- 5 zI!_b d _______._.| |/=
Rernitter U '-
Chack thI, 2 d 8 1 3 ] }~~ f @[ r1 ,
$ki Arm a t ,. ., _ g,;3 4-d_ , , _ _ _ _ _ _ ;I
. 8% : *" = rv - M - - - . .~! wJN , Ty p. of F e e _ j&x,_ ~ ~
~~
*
--~~'*--N ~ . w '~ ' b ec'd. . ' _ . _ _ Ri\ p
-- NNO- ' " -bOy 7te Ccmp!cie/_hh_ __ ,d__
bit:t W: _ . . _ _ . ._ j
.
Roanokr Memorial Hospitals ,
Belleview at Jefferson Street Ibst Office Box 13367 Roanoke, Virgitua 24033 Telephone 703 981-nKx) {
C____.______._____.______ _ ____________________.____________________________________________________________]
- __ _ - . _ _ _ _ _ _ _ = _ - _ _ . __-_ _ __ __- _ _ ______ - - _
) . 2.
.( . .,
E',
. Subject: Renewal Application Letter Page 1 of' 2Ref: NRC Materials License #45-01291-03
'2.a. License #45-01291-03
2.b'. ' Licensee: Roanoke Memorial Hospitals
2.c. Address: Radiation Therapy Departmenty' Belleview at Jefferson Streets
P. O. Box 13367Roanoke, Virginia 24033
2.d. Teletherapy Unit Location: T eatment Rooms #2 and 4Cnneer Center of Southwest VirginiaJefferson Street and Weller LaneRoanoke, Virginia
2.e. Location verified as same as noted in letter dated November 26, 1980.
.(Subject: Request for Amendment No. 17, Condition No. 10, issued June 5,1981). No changes have been made that affect radiation levels in
.
surrounding areas or thai affect the patient viewing system, since letter.dated February 7, 1986. (Subject: Source replacement notification).
2.f. .The electrical.or mechanical stops that limit use of the primary beam cfradiation are still installed and continue to operate as described in thelast survey report submitted, dat ed February 7,1986. (Subject: Sourcereplacement notification).
2.g. The radionuclides, the description of sealed sources and teletherapyunits, the maximum possession limits, and the authorized use have notbeen chaaged and are correct as per previous license renewal application
[dated May 27, 1983, and letter dated February 7, 1986. (Subject: Sourcereplacement notification).
2.h. The list of authorized users as per letter dated January 31, 1985(Subject: Request for Amendment No. 20, issued April 1, 1985) is correctwith no additions and with the following deletions:
1. Marvin N. Lougheed, M.D. - retired2. Robert J. Murray, Jr., M.D. - resigned
2.1. Joseph L. Surace, M. Sc. is the Radiation Safety Officer as per Previous ,
license renewal application dated May 27, 1983, Appendix II, Attachment /Form NRC-313M Supplemant A.
2.j. Item 8: Training for individuals working in or frequenting restrictedareas.
We have adopted the training program as described in Appendix D of DraftRegulatory Guide FC 414-4.
Item 10.5: Operating proceduresSee Appendix I.
-- - _ - - _ _ _ -
- - - _ _ - _ _ - _ _ _ -- - . _
*
, ,
-..
U 4
Subject: Renewal Application Letter Page 2 of 2. Reference: .NRC Materials License #45-01291-03
~2.J. Item 10.6: Emergency ProceduresSee Appendix II.
' 2.k. Item 10.1: Personnel Monitoring Program'We, Roanoke Memorial Hospitals, have established and agree to followwritten procedures for personnel monitoring that include'as requirementsthe criteria specified in Item 10.1.2 of Draft. Regulatory Guide FC 414-4.
Item 10.2: InstrumentationWe, Roanoke Memorial Hospitals, will maintain and have available for usethe instrumentation specified'in Item 10.2.2 of Draft Regulatory Guide FC414-4.
Item 10.3: Calibration of Portable Survey InstrumentsWe, Roa~oke Memorial Hospitals, will calibrate our own survey instrumentsn ,
in accordance.with written procedures that include as requirements the !
criteria ~ described in Item 10.3.4 of-Draft Regulatory FC 414-4.
Item 10.4: Leak Test ProgramWe, Roanoke Memorial Hospitals, will establish and agree to perform theentire leak test procedures ourselves in accordance with writtenprocedures that include as requirements the criteria described in Item10.4.6 of Draft Regulatory Guide FC 414-4. See Appendix III. !
2.1. No changes have occurred in the information previously submitted in the!license renewal application dated May 27, 1983, Appendix IV concerning
other aspects of the radiation protection program or the teletherapy ;
program.
2.m. 1. List of radiation safety committee (RSC) members - see Appendix IV. ;
2. RSC and RSO duties and responsibilities - see Appendix V |
3. We, Roanoke Memorial Hospitals, egree to (1) ensure that the member- |ship of this medical institution's radistion safety committee shall !nt all times include all personnel specified in Paragraph 35,11(b) of10 CFR Part 35, and (2) will maintain recoins of that membership juntil the NRC terminates our teletherapy license,
d
| 2.n. We, Roanoke Memorie.1 Hospitale, have 3dopted the model ALARh program j
| described in Appendix J of Draft Regulatory Guide FC 414-4, since ;
i August 15, 1980. j
2.o. A source renlameinent occurred on January 14, 1926 and the required surveyreport was subruitted to the NRC in letter dated February 7,19M.
ii
i
_ _ _ . _ _ . _ . _ _ _ _ . - __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _
_. - - _ _ _ _ _ _ _ _ _
Q ' i :.t. .n. ,i
,
? , . .
{{."
, /) . - g y
. ..
ei;
;1
r
(-,! .
APP'..sti ' I< .
- - - - - - - _ _ . . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______,__ __ - - - _ - - - - _ _ _ - _ _ _ _ _ _ _ _ , _ _ _ _ _ _ _ _ _ _ _ , _ . _ _ _ _ _ _ , _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ ]
e,.
m . .,
i. .. ;# '. .,
. .,
4: _ - ' ,
,t (
.RADIATION EMERGENCIES .,
1.<,
'
' SOURCES OF' ASSISTANCE-
Telephone
Home Office.,
"
| - Mr.' Joseph Sur sce, RSO 345-7871 981-7379
Margaret Harvey, R.T. T. 989-8682 981-7377
Mr. Jack Wakley' 977-2671 981-7379
-Kathy Arritt,-R.T.-T. 344-4559 981-7377
Hugh'J. Scruggs, M.D. 982-2342' 981-7377
.
Mr. Jeffrey G. Messinger 344-7492 981-7379
Arthur B.'Frazier, M.D. 343-7770 .981-7377
R. Lewis Royster, M.D. 989-2136 981-7377
CITY OF ROANOKE OFFICE OF EMERGENCY SERVICES -
Mr. Warren Trent 566-5656 981-2425Director
Lt:. Willien Mayo 362-5092 981-2286Police Fcree
Mr. Glen Lyle 362-1194 389-7271Staff, Radiological Defense
i
. Virginia State Department of Health (BRH) - Central Office, Michmond, VA1-804-786-5932SW Regional Office, Roanoke, VA(703) 982-7411
1
Nuclear Regulatory Commission - Region II Atlanta, Georgia1-404-221-4503
_ . _ _ _ _ . _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ ... J
__-_- - __.
. - e. .
Woende .Ecoual $ $$ '
'~
$.
.
!. . t
', ;ry, ,
e
. .
*
|.
'T0: All Departmental Personnei-
FROM: , Margaret Harvey, R.T.T.Technical Directer
SUBJECT: Radiation Safety Policy,
EFFECTIVE: March 27, 1987-
Upon completion of a radiation procedure in any of the treatment' rooms,only the'last:' person leaving the room should close the door or activate theelectronic door. closure- appratus.
.This procedure should' minimize the charice for radiation' incident.
daurnae --
Margaret ri rvey, R. I . I ..\ V.
cc: Joe Surace,Radiation Safety Officer
mtp
.-
m_____m._____________..__,-_______.______.______m._.____.-__.m___. .____. __m..-._. ..._ . -_. _.m_. m __.m_ _ _____ _ .- -
_ _ _ - - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . .
R.M.H.: POLICY AND PROCED4RE 1%NUAL -Revised: Janua ry,1982q
LL G, -
iM I. RADIATION SAFETY RULESO,i T ',!" W I. Personnel ProtectionQlg'
,
W All technical personnel in the department are required to practice andLil follow the rp'adiation safety rules. -
4' i.V, A. All technical personnel shall review annually Title 10 Parts 19jj and 20 of the Code of Federal Regulations of the NRC. -(As per Policy' !!r and Procedure Manual. for Radiation Oncology).
T! B. Personnel film monitors are to be worn at all times while in the work3 area. They are to be stored in the assigned location in the' depart-
R ment when not in use.T C. Doors to treatment rooms are to be closed during treatment, except asQ noted in memorandum of 3/16781: (attached).g D. Doors. to treatment rooms are to remain open at all times except when
an exposure is being.made.g
@j E. When a machine is unattended, the console key shall be removed to a,
2; . secure . location. -
$ F. Door to the simulating unit will be closed while an exposure is being:9 made. .
Tij II. - Patient Protection
,
4 _
A. Patients undergoing treatment shall be under direct visi~on usingthe TV monitor or through the lead glass window by ,the attending
j technologist, or staff member.-,
B. The technologist sh'all use the intercom system for patient communica-. . . tion during the treatment.
C. Be sure the correct patient enters the treatment room and Theck the'.
photograph 'in the chart. If.the patient is in-house, be sure to4 check I.D. bracelet'.' . -
R D. Before treatment is administered be sure the prescription is clearlyS understood.
'
-
.E. Be sure dosimetric. calculations follow the prescription.:.
F. Use immobilization devices for all head and neck patients and for"* any patient when necessary. -
y G. Be sure all treatment parameters, patient positioning, and dose setd tings cro correct before administering treatment.-t H.. During treatment, console treatment parameter must be monitored byW attending technologist.-
9g.
!.j III. Physics Checks -
^
A. The calibration of therapeutic radiation producing equipment is pery formed in arenrdance with NCRP guidelines, NRC regulations, and VirginiaM' State. Law. The record of these calibrations is7., maintained'in the Physics /nausatiusi afety Office.'
B. Monthly output factors shall be posted in designated areas and kept on fit,
4- C. Interlock ' system checks for .all access doors to the treatment rooms/ are performed monthly and a record of this is maintained in the Physics 0-
\@ D. All rules and regulations of the License No. 45-01291-03 and No. 45-01291-'
for radioactive material by the NRC will be enforced. A copy of this-
license will be kept on file in the Physics and Radiation Oncology Office! i
- - _ - _ _ _ _ _ _ - _ _ _ _ _ _ _ - _ _ _ _ _ _ _ _ _ _ - _ _ _ _ _ - . _ _ _ _ _ _ _ _ _ _ _ _ - - ___
_ _. --
' '.
,
|,. ..,
4
o .23-
REPORT OF INCIDENT--
.1. DEFIN TION
An incident may be defined as any event or condition in the*
Hospitals which is considered to be abnormal, or which results in
| the injury to patients, employees, visitors, or other persons on
hospital property.
2. WHO EEPORTS
A. The employee vie is directly isvelved or responsible for or
who first. becemes aware that as incident has occurred, is '
responsible for reporting. the incident.
B. If the incident involves personnel from more than one service
or department, all persons involved should report the in-
cident.. -
3. REPORT TO WHOM
Incidents should be reported t > the i=2ediate supervisor or~ a
department head on duty at the time of the occurrence of the in-
cid ent..
4. us?.T
The immediate supervisor shall be res >cnsible for insuring an !
'" Incident Report" form is initiated, which shall ine)udet.
A. All pertinent information requested on the form..
B. Documentation of the complete and thorough investigation ofl1
the events Icading up to and the result s of the incident. As
follows:
Tor case of completion, there are two t ypes of incident J
reports. The green form is for incidents involving e ployees
(g .and the yellow f orm is for inciden'ta involving patients or'
visitors.
12/81
>
_ _ - _ _ - _ _ _ _ - .
,
'
y. -
:. ,v.i ,
-@ POLICY AND PROCEDURE MANUAL.'
REVISED FEBRUARY 1983E4
j OPERATIONAL PROCEDURES FOR THERATRON AND ELDORADO
, ;.
|q 1. Insert key into "on-start" slot on the control panel. Key must be'ini vertical position before operating unit.|ZQ ~ 2. . A ~ series of check ' procedures will be performed before treatments are-,y begun at the start of each working day.
&-2 a. Check radiation alarms for operation? b. SSD light indicator is checked :with. SSD rods. These are checked'' in the vertical and lateral positions.j| c. Table and head movement operations are checked.4 d. All source indicator lights are checked. ,
g e. Check operation of intercom and T.V. monitors.:.p f. Mechanical and electrical checks (Refer to mechanical and
- electrical procedures).5y.vi 3._ Assist patient onto treatment table and assure positioning according? to technique instructions as ' recorded on i.he chart. Be sure' patients is properly immobilized. If disoriented, restraining straps are used.g ..
-.}Be sure to ' place all blocks on the shadow ' tray BEFORE positioningpatient under the gantry.
4 4. Carefully review the treatment chart to assure all instructions are' *i followed.
&d 5. After the final check of the treatment set up, instruct the patient
9 to stay in position until you re-enter the room and give the okay torelax...c.
.c
:/ 6. On the Theratron, depress " console" button on the hand control and beg sure door is completely riosed when leat ir,g the treatment room. On
the Elderado, be cauticas of the large door and be syre all perconneln.
;#. are out of the roam befure activating the dcor mechanism.'R .
'
w 7. Set the timar according to treatment time recorded to deliver teh9 . prescribed dose. !
':f!
l{ ^ a. Depress modc of treatment desired.iy b. Depress reset button.
JQ c. Turn timer to "on" position.0 * d. If rotation, art, or skip arc mode is desired,y a, be sure pantry clears patient and t able top by making a4 complete rotation.'q b. arm speed should be set on .5.r.p.m. .
Lt* refers to Theratron only
'
.
_O~
3 |
.
.. ;
- _ _ _ - _ - _ _ _ _ - _ _ - _ - - _ _ _ _ _ - _ . - _ - -_-.
. _ _ - _ _ _ _ . _ _ _ _ -_
' *.
*,,m- , *
Edf; ' 8. Be :avare of all source indicators while treatment is in- |," progress;and maintain visual and auditory contact with
s-0 .the patient.
d.;f]ct~Q. 9. When1 treatment has been completed,-be sure. source hasf|,j returned to drawer and enter room.. y;' h'E. ' 10. Record treatment information in patient chart as to.yfj treatment time, dosage, date, and initials.^ :b .30~ a . ') If patient is an in-patient, the hospital chartJh,;' is stamped with the date and dosage given and.f;1 initialed by the Radiation Oncologist., .;:,n
,
. m" ~5 11. Assist patient off of treatment. table-and instruct
:Ilh them when to return.?ib
j' y -j 12. The room will then be cleaned and prepared for thenext patient.;.,jj
! &.N:,3-
.
, . ,'t.'; - .
,
.y
h' D..t * ONLY THOSE TECHNOLOGISTS CERTIFIED BY THE AMERICAN REGISTRY-y<d 0F' RADIOLOGISTS"IN RADIATION THERAPY TECHNOLOGY SHALL ADMINIST1*
TREATMENT AND SUPERVISE OPERATION OF THE RADI0 THERAPEUTIC-
M(}} EQUIPMENT. TREATMENT IS ONLY ADMINISTERED UNDER DIRECT ORDERS(..
6 AND UNDER SUPERVISION OF THE RADIATION THERAPIST.
k " =2TL*bci: ::::6' l,<o;.
,$Y.W
<. N':M '
h* !.
, t+- 3',
L Revised October 1981'
.
{, , .'. ,1'3.?, ,:
dI. , -
| ?.3*
.h ~'
.
'c f
.e
. - - _ - - - - - _ _ - - . _ _ _ _ _ . _ _ . - _ _ _ . _ _ _ . _ _ _ _ _ _ . _ . _ _ _ _ . _ _ _ _ _ _ . . . _ - . . . _ .__ __ _ ..__ , , _
._ _ _ _ _ _ _ _ _ _ _ _ _- -
, ,a ,
|. ' ! RMH _.; Policy and. Procedure.Masual.-November,fl981- ,
#,tL I,
.
' - ' IMMOBILIZATION11[(dV. .
I. Plaster casts,|I
Occasionally an immobilization devicefis necessary for cases.
in which beam direction and isocentricity is uritical. A'' plaster shell or cast is the most common.
Procedure for construction of cast'
1. Inform the patient what is going to be done and'why.2. Have all. supplies ready for use:,
f. a.,-Eoroc plaster of paris bandages cut the appropriate.
R length|h b. Basin with lukewarm water[l c. K-Y jelly
d. Saran wrap4
!- e Tape
1 f. Wa sh: cloth & towel- 3. On maxillary antrum or pituitary patients, take a cross
table lateral film before beginning the cast to verify--.
Lj proper positioning of the patient. When. using bite block
f' be sure it is in position at the time of the film.,
4. If the' cast must include the head (scalp)', saran. wrapcan be used ef f ectively by wrapping it' around the head ' '
.
((f) securely. Tape may be used to fasten the saran' wrap to|
.
the head. Small pieces'of saran wrap can be placed overthe eyes to prevent plaster Trom getting into d}es.
-
5. Apply'K-Y jelly to the patient's skin to ensure easyremoval of.the cast after construction.,
6. In construction of the cast, dip the double strip of'
plaster into leukvarm water then gently with your firsttwo fingers, slide the excess water off of the strip.Apply the plaster bandage to the area of interest.
K 7. In covering the area, the plaster strips should be
l[ smooth, without gaps or air bubbles between the skin|; and cast. {Lp 8. Be sure to include at least two enforcement points asL the nose end/or chin within the casted area.
9. Place a second laye r, but single, strip plaster bandage*
i over the entire area for support.10. Smooth the bandage with fingers to ensure proper moulding
of.the two layers." 11. Unit approximately 5 minutes for the cast to dry cu the
1 patient.',
12. Gently rencve cast.13. With warm water and soap wash K-Y Jelly and excess plaster,
off patient..
14. After the cast has completely dried, trim the edges and'
any rough areas. -
.(O:
_ _-__ _ _ _ - _- _ _ _ _ __ _ - _-_
_~ .-- - - - ~ _ _-Page 3' . -
,
..,
|-
. II. Bite Blocks,: !
t . In particular head and neck cases a bite block is necessary to,
2.- immobilize the tongue in position.p.T There are several types of bite blocks that can be used:$fy{.jp 1. Dental wax conformed around a plastic airway.
2. Cork with tongue blade.'h 3. Distal end of a 30-50 ce syringe.|-
; o| d .Y
N The most commonly used in this department is the distal end of a$ 30 cc syringe.
'Q'.% III. Lead Masks
It is sometimes necessary to construct a 3ead mask for shielding
)fii as well as 1: mobilization for superficial / Orthovoltage patients.A;
:- A. Procedure for mask construction
'i f,; 1. Inform the patient what is going to be done and why.,,j 2. Have all supplies ready for use:
,
&yr a. Jeltrate
h b. Mixing bowls .
?*?,jT3 c. Spatula
<0 d- ' ""' ' "2""**' ' "''''2% N e. Zoroc plaster of paris bandages cut the appropriate.' length.
_,, ,.
f. Basin with leukvarm water. |y'7 g. K-Y Jellyyr h. Saran wrap, - " . ' i. Tape
j. Wash cloth and towels>
;- k. Sheets of lead1. Solder
3 n. Soldering iron,
.pjj n. Rubber tip hammerf.'{ o. File
,'G p. Wax.5y"p.: 3. If the area to be treated is around the eyes, nose, or errs,'3 a Jeltrate impression should be done initially.,
.
:C4 a. Outline the treated area with geritian violet.*
h b. Mix the Jeltrate powder with 2eukwarm water until a,0 pasty consistency is achieved.:p c. Apply the paste to the are of interest quickly as theJg solution hardens and shrinks.(.|;. <O
'
f February 1978'-
' .:
_ _ . _ _ _ _ .____ ,_
Pago 4 . ... , . .
r *Y 'd &
W:<. -
9,: ~i III. Lead Masks Continu2dC.f{p, . ([ - 4. Apply casting' material over a generous area.over and'
A?p surrounding the area to be treated.
I,{.jjc (Follow casting instructions) >
y :%7>
d; . , 5. k' hen the completed cart has hardened sufficiently removr27 $7] it carefully.
c.%,~
k j& 6. Fill in holes and build up walls of the cast.
h.... M,M'.
7. Have someone clean plaster and K-Y from patient...5"'..s. .,
<. . . ,.
'at;E 8. Mix coccal or plaster according to manufacturers"
0 - directions..
. .
ha' 9. Reenforce outline of aren to be treated with gentianviolet on inside of cast.
. $. .V"h;'
?k'
" ~'
10. Coat the inside of cast vith K-Y.ft'.t;jj'j .
,, ,
y%..i% w*3 #j3 ./ jg1
: 11. Peur the coecal into the cast. Pour an ample amount so'
.,p. .<] the positive impression will be easy to work with.*-
12. Let the plaster or coecal harden. (Several hours).- ".
. ..
'
3 13. Carefully remove the cast from the positive impression.M -
14. Clean the K-Y jelly and bijs of plaster from the *y,,,,. impression.-
".it.4 9'. ll i. 15. Cut sheets of lead and by pressing and hammering, conformv. . - -M:.w lead to impression.;ry.m
16. Solder any creases and smooth all rough edges.|. };
[_)h 17. Cut out area to be treated.'
.ShG.&- 4 18. Coat with a thin layer of wax.
1?.h,
n *., Ty
t.. T
| f(M d;.1.'.
1.;, g 4
[:?.Q?V
| i{fS Revised February 1978 ;
%rj:-4 . !
?.
i
*1*-' " '- ... *
....9
|
,
m____m.._ _ . _ _ . _ _ _ _ _ .__.m.___m._____ _ _ . . _ _ _ _ _ _ . _ _ _ _ _ _ _ _ . . . _ _ _ _ . , _ , _ _ .._____.____ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _
. - _ - _ - - .__ -_ - - .. . _ _ - _ _ _ _ - _ _ _ - - _ . - _ _ - . _ - _ - _ - . _ - _ _
'
R11H PON CY AND PROCEDURE P.ANUAL-LOCTOBER,.1981-. . , ,
"
. t(: DOSIMETRY PROCEDURES. . .
g..,
' .,
N,O ~
Patient dosage calculations.
-
; ,
y I.m
A. The initial calculation vill be'done by a staff(J.j;, technologist' or dosimetrist.
..
yp,' B. Eaci calculation must be checked by a second staff
P technologist or dosimetrist.4 !
f.9 - C. All calcu?.ations shall be recorded onfthe appropriate
'h . parameter forms..
wlD. All values necessary for calculation are' located in.[j'
the calculating data books or the BJR Supplement II':fp- and are maintained in Dosimetry Planning. ."
II. Chart review.j
, " 3 vg } 9g { ~~~~ [ =~'~ ~;7 m ,-
~~
u ,
,
'B. Contouring..
,
E. .
t,
() 1. Information verified.and, recorded..
a. IFD,1
b. depthc. 'ffeld size and/or volumed. edges..of field-and center
,
l e. patient's namef. date
,
g. any pertinent information-
C. Computer operation.
,1 . Operation of the computerois by the Physicist'.. ,
Dosimetrist,-or staff technologist assignedto dosimetry.
2. Operational manuals are maintained-in thecomputer ro'om for review and reference.
3. All plans done on'the. computer will be assigneda file number and recorded in the log book.-
4. All plans must be reviewed by the RadiationOncologist before values are used for calculation.
:
- ..
OCTOBER, 1981
'k h.
- -
__ _.___ _.-__-_ _-____ __ _ _ _ _ _ _ _ _ _ - - _
Policy and': ProceSure " Manual.:; 0c.t ob e r ,'.19 81;a'
,
y7
, -
;(EQUIPMENT.-CARE
i
'The Technologist Must:~
'
1. - Operate the equipment in a scfe and carefulmanner.
2
2.. Always have. object's clear.of the machine'.whenit'is~in motion.
'3. . Remove tape from'the machine after each treat-ment.
4.. Never: lean or place objects on the treatment-Console.
5. Replace :all trays, block, etc. in their properplace'after each use.
.
6. Report immediately any defective equipmen: -
irregular operation, loose or tight ~ screws,scratched or~ adj us tments. *-
~~
, .
-
- .
||
.
O
!
|
(
c_____________ _ . _ . _ _ _ . _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
,- ,,. - - ~ - , - . , , - n-
_ _ .
-t . .
; .
8autemswr ' lames
Mecanatcat.Tmte.
St_te reome%e.g. -
Doot StusTCH
RAciAvtou DETs.c toa. |
'TisaTMENT 1 Aat E |'
hvs~ikard AoneTcas (
@AwTe r MECRAM\ CAL
Got.uxsTse. Mtewastcas. I'
|Morte6 top (Emmtacy) . .
@ Soutestav .luxtetocxs$6AKhN TAU OF DAT j~ -- :z
)
ANY .D15CREPEMC\ES W\\ L BE RE.POR.TE. b T o T B E.,
PINS \CG. DEPT. AMD E\bMEb\t A\ ERGiMEER.\MG ,
bResCTNE. N AlMTEM A MCE_
.
W T*o .
.
D$bMfb OM# 9 etfas. fM %
_
e
O
.
DEPARTMENT OF RADIATION ONCOLOGY~ '
-,.x_._/ QUALITY ASSURANCE PLAN
- =
.
|
|
|1
0|
L-__ __ _
- _ _ _ _ _ _ _ - _ _ _ _ _ _
. i..
.. .
EROANOKE. MEMORIAL 1 HOSPITALS*
*
CANCER CENTER OF SOUTHWEST VIRGINIA.
DEp.ARTMEET OF RADIATION ONCOLOGYI ~ QUALITY ASSURANCE' PROGRAM
I. PURPOSE:,
The purpose of'the Quality Assurance Program is to have.a-mechanism at the departmental. level to assure an optimumlevel of care and treatment consistent with the goalsand objectives of the Department of Radiation Oncology-and Roanoke Memorial Hospitals. This quality assurancemechanism is to be maintained and improved as indicated,
II. INTENT:.
The Radiation Oncology Quality Assurance Plan-is part ofthe comprehensive and integrated Quality Assurance Programof Roanoke Memorial Hospitals.
,
Although quality assurance activities are in existence inthe department, this plan is designed to expand and coordi-nate all quality assurance activities.
,
The plan will focus on problem identification and willprovide a process for determining solutions to those problems.The plan vd11 require on-gof.ng evaluation, action, and
{ ' follow-up.-
~
Reports of -the. Quality. Assurance-ectivities will be forwardedquarterly to the Administration. Annual review-and re-appraisal of the Plan will be carried out on a departmentallevel.
III. GOALS AND OBJECTIVES:
A. Goal: To render an optimum level of patient care thatis synonymous with Roanoke Memorial Hospitals byproviding a quality Oncologic Service as a partof the multidisciplinary effort to cancer manage-
,
ment.
Objectives:
1. To reduce patient whiting times2. To ach eve technical accuracy
,
3. To improve professional skills and showevidence of continuing education.
4. To strengthen communication and coordinationof efforts between.the referring physicianand oncology physicians for each patient.
5. To strengthen p,sycho-social care for each-
Jpatient.
;
_ _ - _
. .'
L n .
k.DEPiRTMENT10F RADIATION ONCOLOGYV
.
! Quality..ssurance Program.
L('0Page *2
'
s'pport and/or advise rehabilitative care followingv.. To ua course of' radiation treatmen~.
7.. To condutt patient and family education sessions;to
Lencourage' understanding of the disease and management:of same.
8. To minimize. recording errors by an on-going review ofactive treatment charts.
9. To. actively make use of the Tumor Registry to evaluatetreatment approaches and results.
B. Goal: To assure peak efficiency of the radiation producingequipmept in the Department of Radiation Oncology.*
Objectives:
1. To measure and record all data on each unit with minimumrequirements as governed by U.S. Department of Health,-
Education and Welfare. These measurements will be co-ordinated by the Radiation Physics Department.
2. To schedule and record Preventive Maintenance Service,
visits on a timely basis and correct all problems as soonas possible. ,,
/1 .- C. Goal: To assure departmental compliance with the NuclearRe';ulatory' Commission.4 *
~ *Objective:
,
1. To meet all standards and requirements of the U.S. NRC
license 45-01291-0S and 45-01291-02 as it relates to the~ Department of Radiation Oncology.-
D. Goal: To provide a safe environment for patients and employees.
Objectives:'
1. To reduce incident occurences2. To provide periodic in-service sessions on hospital
safety for all employees.3. To enforce departmental and hospital safety rules and ,
regulations. ,
.
G
O.
_.-m.. _ . - . _ - . . _ _ . _ _ . . .
,. _ - _ _ - - . ..
. .
,
J E *
?-DEPARTMENT 0F'RADIATIOP' ONCOLOGY |- Quality Assurance Progr.
'
--P a g e' 3 '.O .
-1' : E. Goal: To mair.tain an Educational Program in Radiation
Technology with:the highest possible standards..
Objectives:
1. With meeting the Essentials of an AccreditedEducational Program in Radiation OncologicTechnology, the program will:
For the Student:
A. Provide an opportunity-to obtain a high*
1evel of mastery of the technical ~andprofessional skills of a RadiationOncology Technologist.
B. Provide a firm educational backgroundand qualifications to write and passthe national registry examination.
For t h .. Commuto i ty :.
A. To provide for the community and surround-ing area with qualified Radiation 0ncologyTechnologists to care for the patient by
.
(f'T) carrying out those duties and responsibi-lities as assigned under the direction of.the Radiation-Oncologist. 2
IV. SOURCES OF DATA:
A. Medical Record reviewB. Safety Committee FindingsC. Infection Committee FindingsD. Incident reportsE. Staff Survey - ex.it interviews
'F. Patient QuestionnairesG. ObservationsH. Audits.
I. Joint Commission ReportsJ. Licensure and Insurance reports.
This list will be updated and revised as indicated.
V. ' PROCESS:
The Quality Assurance process will provide and organizedmethod to assure workability and. documentation of theQuality Assurance Program.
'
|g(]) The process will first identify the problem and makeassessment of the problem causes. The next three steps ofdeveloping siternatives for the problem' solving, determin- iing of priorities, and deciding on actions to tske will
____ _____-__. . _ . _ _ _ _ _ - - - _ - - _
._______ _ - _ _ _ _ _ _ _ _ _-_-
, . , .
. -,
'
; DEPARTMENT OF RADIATION ONCOLOGY -,
,; .-Quality: Assurance ProgramiPage-4
4.
.V . - Process (Continued)
provide a systematic approach to implementing the'- '
decision of actions.
The success:of the process will..be learned by monitor-ing what has been~ implemented and complete' documentation!
!< of the entire process. Annual review and evaluation ofthe progratn will be necessary to continually. update tomaintain-the high standards of Quality Assurance as '
. intended.<
'
i
DATE OF ORIGIN: January, 1980DATE OF REVIEW: October, 1981
.
.
s
.
. - 8,,
.
- .e
00
*.
e
e
4
;g ..
___ - - - _ _
i
!RMH-POLICYLAND PRO'CEDU$.E' MANUAL..
~
|3,. OCTOBER, 1981.
3
.
''n ...
ELECTRICAL AND HECHANICAL. !~
f'. O 'J'JOS^rtn ro''c' iCANCER CENTER j
D, ','i' DEPARTMENT OF RADIATION ONCOLOGY j.
x :.:idI'/d
' $ f...f. I. INTRODUCTIONw ,*i
-e. $
p.4,!'M A. The following policies are directed to the employees.;
>
and students in the Radiation Onctiogy Department.ik$MT B. Radiation. therapy units are very heavy machines with !
.. h.yS'};'
many complex moving parts and require high electrical i
d voltages and currents to operate.' Improper usage or'
3d7 . failure to detect defective equipment can cause very.7S - serious injuries to both operator and patient.| {,h .,
|
: ; C. All employees and students must exercise extreme caution"
$ while operating equipment and must obey all safety rules.b-
",}k)>*. II. GENERAL.c.
'
:'$[.hh: C.A. Emergency Shut-down
if;y.' 1. Treatment rooms 2,3 and 4 are equipped with an -
.
g emergency shut-down push switch located at the.qh p operators position at the console area. In thegfi . L. event of a Radiation, Electrical; or MechanicalJ$$ . emergency this suitet is to be depressed thereby.-
':N>q removing all electrical power from the treatment1. r o o m'.
TOM. 2. The Radiation Physicist,. Biomedical Engineer, and1.f.| Department Head shall be notified immediately ofR$ any emergency situation.
. %,yrhy|j B. Fire procedures specific to equipment roomsg.5
7.1.' k 1. Treatment rooms 1, 2, 3, and 4, simulator rooms:I 1 and 2, the computer room, and the large storage
N:c : ' t.room are equipped with an automatic or manual
.? Halon 1301 fire supression system.1Q-? 2 ' 2. In the event of a fire in any of these areas, the
,.!" |[J following procedure is to be followed:
}A|. b.. n. a. Remove patient from treatment room and clear, ',f; all personnel from the treatment room.
[n...'',;.-
b. Close treatment roo'm door.,,
.
: c. Depress emergency shut-down switch located at,- operatora position at the console.
', . | -|
'
<|.
. .- ._ - - - - - - - _ . -- - _ _ _
,
... . .
.+i w,
-
~
3 d. Locate'and' activate;the Fire-Suppression. switch (red-toggle' switch outside of. door)
i
.e.. Notify: the hospital switchboard of CODE' RED' ,
giving exact. location and1 repeat thefCODE..'
NOTE: ' Activation of the Halon 13011 Fire.Suppresion'system'should automatically notifyLthe main hospital;
-
switchboard and the Roanoke Fire Department ofLthe-,
fire ala'rm. .To assure that the alarm has been~LL transmitted 1 call the: hospital' switchboard for
verificat' ion.
f. FollowLthe general fire' safety. policies andclear all patients, visitors, and personnelfrom th e. area and assure.all doors ate closed.' '
~
C. Hevatron, Theratron, and Ximatron Gantry andTreatment Table
1. At the end of the treatment day the gantry shouldbe positioned at Oo therapy minimizing' mechanicalstrain from the gantry drive components.
.
2. At the end of the treatme.at day the. treatment tableshould be.placed eithe. directly parallel or directly~perpendicular to the gantry to insure that in case
,/]3 of a, gantry mechanical failure, the gantry.will notL collide with the treatment table.
*D General, Electrical Safety - Responsibilities
1. DEPARTMENT HEAD
a. Assures:that all electrically operated equipmen'tand accessories are checked by-the BiomedicalEngineering Department on a scheduled periodic.basis,
b. Assures that all unsafe electrical wiring or '
equipment is repaired as soon as possible withimmediate notification of Biomedical Engineering.
:i-
Makes general periodic checks to ensure electricalc.safety.
d. Assures that all personnel are following t'heelectrical safety policies.and procedures,
e. Assures that all personnel attend in-serviceconferences on electri' cal safety in hospitals.
$h I
__ _
- - __________ - _ ,
'
2 '. ' .Pers.on'ne?,e >~? a.. Personnel vill adhere to the electrical safety
-policies and procedures.,
,;] . -
J'f -- 'b. Any unsafe equipment or power cords must bei reported-to'the Chief Technologist and Biomedica'I'
~
jg Engineering. An employee shall not attempt to
' 9| repair equipment. Only authorized personnel
133. shall make repairs.1
'
c. All' personnel shall attend in service conference's.; ~q on electrical safety in hospitals.
| t,s';-
Y0:T d. The following procedures should be performed
daily by each employee where applicable.,,,
[j/1. Check all visible electrical cables for frayed-
@ coverings or broken insulation.
.h[: .2. Make sure that power cords for accessory
5., i equipment, i.e., suction machines, oscillator7, saw, hot plates, etc. are 3' wire conductors
, ,,, j with approved hospital grade plugs.*
-j .
3. If at any time anyone in the department feels-g:i a shock or a patient complainc of being shocker3;
di turn off the unit and remove the patient from-'$ the room. Immediately report the problem to
W,'I h.h the Chief Technologist or appropriate supervistthe Biomedical Engine:tring Department and/or
D the Radiation Physics ' Department. m8,1 4. Assure that all electrical cords'are properly
ff secured in place so as to prevent tripping or'1 equipment being tangled with viring..
ff:' 5. If a burning odor or smoke is noted while: working with equipment, immediately turn off
the unit, assist the patient out of the room as-
': notify the Chief Technologist or appropriateTi supervisor and the Biomedical EngineeringJ. Department and/or the Radiation Physics
% Department.-..
. ' .'.
y October, 1981':
,
/ ,O '
_ _ _ _
_._____ __._____ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ . _ _ _ . . _ _ _ . . _ _ _ _ _ _ _ _ = _ . _ . . , . _ _ _ . _ . . _ _ _ . . . . . _ _ . _ _ _ ._. _ _ ._. _ _ _ . _ _ . _ _ . _ _ _ _ _ _ . _ _ _ . . , __
1
, - 4.
8'.
t.
?,_,
APPENDIX II
__._ _ _ _ _ _ .
~
Revis5 dis ~~0ctobhr, 1986.
-
{ 16. COBALT SOURCE RETRACTION MALFUNCTION PROCEDURES
li
If source fails to retract automatically to 0FF position i1
after treatment time has elapsed, the following procedures shall Ii'
be instituted: j
(Assuming two technologists working at the treatment controlconsole.)
1. One technologist notifies technologists at another treatmentunit or any other staff member of the ' source stick' situa-tion and then enters room to assist in removing the patient.
~
2. One technologist takes the T-bar and enters the treatmentroom, staying out of the primary beam.
.
3. If readily done, insert the T-bar into the unic's head andpush source until only green tape is showing.
4. Then the patient can be removed at leisure and proceed toStep #6. ~
5. If Step #3 is not practical (e.g. gantry at 180' treating .
Ithrough the table) or was unsuccessful, then move tableaway from the machine such that the patient is out of theprimary beam and assist in removing patient from room.
6. Secure door to treatment room and do not use machine.
7. Notify the radiation oncolngist, the Department of Physics (7379),and Radiological Engineering (7614) .
(Assumir , only one technologist working at treatment controlconsole.)
1. Notify other staff members of the ' source stick' situationvia All Page on the intercom (51) by stating:" SOURCE STICK--THERATRON/ELDOR, twice, then proceed"
i|p with Step #2 above.|
cA '
5N, s,ws.6,
b .) ',iy..,'
}if 'F'
e 't'
4
9
: ( (-
v>,-
APPENDIX III
i4
i
i
l. J|
[r-
, .
- - _ _ - . _ - _ - - _ ,
. .
1
Item 10.4: Leak test program
10.4.7-1. A sample is obtairsed using a 6" cotton swab with the cotton tipsoaked in isopropyl alcohol. Samples are obtained from the uppercollimator blade area (just below the source drawer), the lower,
collimator blade area, and the trimmer bars.
10.4.7-2. The following radiation safety procedures are employed during thistesting:
All samples.are obtained with the source in the "0FF" position.a.
b. Disposable plastic gloves are worn at all times when handlingthe cotton swab samples.
Each sample swab is placed in a separate test tube identified asc.to unit and area tested and secured with a rubber stopper.
d. Prior to leaving treatment room, each sample test tube ismonitored using a calibrated portable G.M. meter for any grossradioactivity. Trigger levels: > 2 mR/ hour net or> 8000 cpm net.
(1) If < trigger level observed, proceed with test.
(2) If > trigger level observed, keep sample test tubes intreatment room, leave and secure door to treatment room.Notify RSO immediately,
.After testing individual samples, those which show no radio-e.activity greater than the leakage levels of 0.05 4Ci arefdisposed of as regular trash. Sample test tubes which showradioactivity levels above 0.05 uCi are placed in the cesium jjsafe located in the Nuclear Pharmacy and the RSO is notified i
immediately. 1
10.4.7-3. A NaI(TI) well crystal coupled to a MCA is used for analyzing thesamples and a calibrated Co-60 reference source.
10.4.7-4. See ATT. 7-4-1. )ii10.4.7-5. Joseph L. Surace, M.Sc., designated in Item 7 as the RSO, will
perform this leak test procedure.|
10.4.7-6. We, Roanoke Memorial llospitals, will maintain our leak test records I
containing the required minimum information regarding this test and |the test results for the designated time pe: 2 od of at least three j
(3) years. i
l
iI
_. _ _ _ - _ _ - _ _ _ _ _ _ _
- - . . . - _ _ _ _ _
. . .
APPENDIX'ill - ATTACHMENTS 7-4-1*
F i..
--------------------------------------------------------------------{ RADI0 ACTIVE SEALED SDURCE LEA > AGE TEST RESULTS
---------------------------.....----.---------------- ....----------
|_ ' LICENSEE; Roanoke Memorial HospitalsL
i
Roanoke, VA 24033
LICENSE NUMBER: 45-01291-03
ISOTOPE TYPE & MODEL: Co-60 (MODEL C-146 )
g -ISOTOPE'MF6.i'
AECL
LOCATION OF SOURCES: Cancer Center
DATE OF TEST: 7/12/88
CALIBRATED REFERENCE SOURCE: Co-60 rod (0.102uC1 10/2/80 NEN)
TESTING INSTRUMENT: MF6 - Nuclear Data-NDB2 MCAMODEL - 880708 ( #84055 )SETTINGS - 180-1024 window
~
TEST PERFORMED BYi J;.L. Surace
94RSO SIGNATURE: :ew
n -
( RESULTS OF TEST: 'SAMPL DPMSAMPLE ID. 6ROSS AVE NET AVE MICROCURIES
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - _ - - . - - - - - - - - - - - - - - - - - - - - - - - - - - - - - _Background 3511 0 -----
Reference 85082 81571 .037Eldo-6 Upper collimator area 3479 -32 < .050Eldo-6 Lower collimator area 3540 28 < .050Eldo-6 Timmer bars 3504 -7 < .050Th-780 Upper collimator area 3422 -89 < .050Th-780 Lower collimator area 3444 -68 < .050Th-780 Timmer bars 3486 -25 < .050---------------------------------------------------------------------Range of background: 3511 +or- 224 dpmSensitivity of SCA: 2220095 dpm/ microcurieMinimum detectability of MCA: .00010 microCuries (must be <.050)-----------.--------------------------------------------.-------REMARKS: N0ne.
?.5
s.
- - i
. . ,
|'. ,
''
APPENDIX III - ATTACHMENT 7-4-1I1
1I
v, , ~..y . n,,s . ,
r
.
1
Te;na u d i 1.t rec tor-
( d n C +'! CC111 M T Of South %PE* VirQlDia
FROM: Rutietion Satety offirer!)erartment 01 Physics
DATE: July 13, 1986
SLb 'u 1 : D'd ige i esting of radio art ive seuimi courcen, i.e.
Co-t>0 sealed source housed within o t elethorapy machine
H h1 1. ':, L 'A f. . *'h <eric}s L i t. ell 3 + NC. M -ijl.'91- U l.
F.s. C.F.k. to twrt ->.59-
t
,
In accordance with tne conditions set forth in the abuse n.>teorefer ences , t he Col.n i t-60 telether 4,y inathines , i . <> . T!wratran 715 ntrea' un' reon 4 and El<h r ada-6 in t reottrent rr.om 2, vrre i e st e<l !or
lea ..t remas cib] s reid iw t i v" nator ia l trem tb<<ir re-pe tise.
hi- td :i t e kUS i!'S Ci th" t e r f r- il- 110t.kla "'4~ .i t'd ! " l s ouri.'e r ah '
. it ihe pr"3ence v: r e p," t . 4 a o a m m ' r ." r s,r: <, W a r-cios' 'i'sic -
' -3 o s hes - t=ste .3r/ rr- 4 o :;n '.=d in ' n ile ;1 J' ' ' '
s i
i ns .- i n tiles (wu M) for tw iew w' i n";4 : tio in nordanc ' u ~. t a
t h- pr esent iicensing conditions coJ rr-gulations, t ht se tesis shall teconducted again in six inunths.
\s i gn e.t u r- : u ._
hadit on Sofety Offico!'
|'
-
I
%
>!L__.___. _. _ _ . _ ._ _ __ _ _ _ _ _ ____.____a
_ _ __p . _ - - .- -.-- - -
,
- --
.. .y : . , -
+,,
I' ' 'q' j g| . p.[, ^..,t > ..,
, ('.
t'i J.
y
I
i
APPENDIX IV
1
i}
!
i
)
1a
1
- - _ _ _ _ -_ - _ _ _ _ _ _ - - - - - - - - - - - - - - . _ _ . _ . __ _ _ , _ _ _ _ _ _ _ _ _ _
, . _ _ - - _ - ._ - _ _
'S ;|., ....
,
, ,,
|)
'Present membership of.the 2SC and their respective titles / staff positiors and. 1
. department affiliation as of 8/15/88:
Kathy Arritt, R.T -T. - Chief Dosimeterist, Radiation Theray. Dept.
1Steve Arthur -' Director of Safety & Security, Chairman of Safety Committee
L ' Robert Beightol', Pharm.D. - Director of-Nuclear Pharmacy Dept.,
: JoAnn Boone, R.N. - Associate ~ Director of Nursing Services
W. Andrew'Dickinson, Jr. - Senior Vice President Administration, (Chairman) |
Margaret Harvey, R.T.-T.,, Technical Director, Radiation Theray Dept.
.Mr. David-Haselton - Staff engineer, Radiological Engineering Dept. ..
!
Linda Hubbard, R.T.-N.M., Technical Director, Dept. of Nuclear Medicine j
;
John Millirones, R.T.-D. - Technical Director, Cardiac Catherization Lab i
' Wayne Oleson, Ph.D. - Biochemist, Dept. of PathologyI,
Stephen Purves - Vice President, Administration ;;
Hugh Scruggs, M.D. - Director, Radiation Therapy Dept.
Jesse Stakes, R.T.-D. - Radiology Service Administrator |Joseph Surace, M.Sc. - Director, Dept. of Physics (RS0)
i
Marshall.Wakat, M.D. - Director, Dept. of Nuclear Medicine j
l
Jack Wakley, B.Sc. - Consulting therapy physicist .)1
William Weller, M.D. - Radiology Dept. -].
|
|
|
8
_
|l
_ _ _ . _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _
7'\. . t_ -,------y-,,,---------------,-- -..-3-------
- -- - - - - - ~ -- -.
_ - - . . - -- - -
_ ,__
N '.,: k4' j' I> y f.
,,
3;( ' a .; f'.'' s . :
,' + " . . ../.-i
.( : q . . ,;' ^ , ., ,
I ,', . . , ' . :7. ip'
t i.''s 3,
l.., .s, , . -
'; 1. - ,
''s .
, 1.T h .t.'4'' .' ^
| ,d g. -1-i
.'',,
..+-
| .; ._
1 i
L3 .v-:
,, e_944--
..
| ' I 4
|
'
-.,.
<
I
- APPENDIX V.
,
,
i,
1
.1
|.,
1
1
|
1,
if
,
f
h,
- . - - . -- - _ _ _ . _ _ . - . _ _ - _ _ . _ ... - _ - _ _ _ . - _ _ _ _ _ _ . - - - _ --- - _ - _ _ - _ _ - - - . _ _ . _ _ _ - - - - _ - - . - - _ - - _ _
_.___-_,1
. . _ - _ - - _ . - __
LR.H.H.:' POLICY- AND' P,ROCEDURE MANuhL'Revised: Janua ry 1982 -'
February, 1985.
.
.Responsibili.ty For Radiation Safety In The Hospital.Including Usage of Radioactive Materials And
X-Ray-Producing Machines
|President
.
Hospital Safety Committee,
s
Radiation Safety Committee
.
(Committee Appointed by Senior Vice ' President)
2 i1j
_ ___ _ _ _ - -
* ,,
UR.M.H2: ; POLICY AND P'OCEDURE. MANUALR"' '
' Revised : -January-1982February _1985s
RADIATION SAFETY COMMITTEE (RSC)
1.~ Members - shall be appointed by the Senior Vice' President and consist ofno fewer than.the following:
Radiation Oncology RepresentativeNuclear Medicine RepresentativeTechnical DirectorExec-aive Vice PresidentPhysicistLaboratory RepresentativeRadiologist-Radiation Safety. OfficerChairman'of the Hospital Safety Committee-
Senior Vice PresidentNurse
2. Function - This committee has the important responsibility of developingpol. icy and action programs relating to radiation safety in the hospital.'-Its members will be available for consultation with the Radiation Safety -Officer or Administration regarding the mechanics of safe handling anddisposal of radioactive material.
Permission to use' radioactive materials in the hospitals shall be grantedafter approval, first of the Radiation Safety Committee and second, afterapproval by the E.C.P.S. and the governing body of the hospitalc.
It is not the function of this committee to approve the medical meritsof a particular procedure, but rather to determine the safety of'procedures.
1
3. Duties:
'
To approve the safety of a proposed use of radioactivea.
material with. regard to the methods of handling, disposingof wastes and experience of user.
b. To maintain minutes of meetings, enumerating decisionsmade. A copy shall be sent to each member.
c. To direct the Radiation Safety Officer to implement their decisions.
d. To take appropriate' action when advised by the Radiation SafetyOfficer of infractions of the rules.
|
e. To meet at least each quarter or whenever necessary for thepurpose of reviewing applications or any cther pertinentbusiness.
- f. To approve the safety of proposed use of radiation-producing jequipment with respect to anticipated exposures to staff and J
to patients. ]
14
- - _ _ _ - - - _ _ _ _ _ _ _ - - _ _ _ = _ - - _ _ _ - _ _ _ _ _ _ _ _ _ _ _ _ - _ _ . _ _ _ _ _ _ - - . _ _ _ . _ _ _ .
,- .
.
*...
R.M.H.: POLICY AND PP30CEDURE MANUALRevised: January 1982
February 1985
j" RADIATION SAFETY OFFICE<
Function - To assure the safe and proper uses-of radiation in this hospital1. . by coordinating the efforts of the Radiation Safety Committee. Administration
and the individual users. To act as a liaison between the regulatory bodiessuch as the NRC, the State Bureau of Radiological Health, and the Administrationof the Hospital.
2. Duties: (a) To advise the Committee of:1. Safety program to be carried out by an applicant
pursuant to a project.
2. Any infraction of safety rules..
(b) To keep records of applications.
(c) To keep records of individual exposures and to have postedcopies of exposure reports. Any case of excessive exposureshall be reviewed with the Committee.
(d) To keep records of shipments.
(c) To keep records of location of sources.
(f) To keep records of surveys.
,,
(. (g) To calibrate users' survey meters.
(h) To dispose of radioactive wastes.
(i) To be available for consultation with users.
(j) To conduct instructional courses for Physicians, Technologists,and other staff as requested.
(k) The Radiation Safety Officer may, at his discretion, give pro-visional approval for the transfer or use of radioactive matettial.However, the appropriate committee must act on this approval atits next meeting.
The Radiation Safety Officer shall inform the user of any contamination foundwhere radioactive material is used. The user shall be responsible for decontami-nating the site as instructed by the Radiation Safety Officer. Protective clothing,masks and special monitoring devices shall be supplied by the Radiation SafetyOfficer where necessary.
Authority of the Radiation Safety Of ficer |
The Radiation Safety Officer shall have free access to all areas and shallbe empowered to clear all persons from any areas at any time he deems that areato be unsafe. Following this measure, he will be required to notify the Chairman
' of the Radiation Safety Committee, or, in the absence of the Chairman of the(,) Committee, any member of the Committee and appraise him of the situation. With (24)
twenty-four hours of the notification by the Radiation Safety Officer, this informedperson shall then call the Committee into session and decide what steps shall bc
;
| taken to correct the situation.
!
15
w- __-_- . _ _ _ _ _ _ _ _ - _ _ _ _ _ _ _ _ - _ _ -