Radiation Safety and Protection Plan. Small Animal Plain Film Veterinary Diagnostic Radiography

Transcription

1 Radiatin Health use nly Radiatin Safety Act 1999 Apprval N.: This radiatin safety and prtectin plan, cntaining 12 pages, is apprved fr: Pssessin Licensee: Delegate f the Chief Executive Date Radiatin Safety and Prtectin Plan Small Animal Plain Film Veterinary Diagnstic Radigraphy Name (pssessin licensee) Signature Date Page 1 (standard plan)

2 Cntents 1 Intrductin 2 Scpe 3 Hazard Assessment 4 Functins f the Radiatin Safety Officer (a) On-ging RSO duties (b) Annual RSO duties 5 Training (a) Training fr all emplyees (b) Additinal training fr users (c) Additinal training fr persns invlved in image acquisitin 6 Safe Wrk Practices (a) Use f X-ray equipment (b) Register f expsures 7 Image Receptrs and Film Prcessing (a) Digital imaging systems (b) Film sizes and applicatins (c) Strage f unexpsed films & film prcessing chemicals (d) Prcessing f films 8 Repair and Maintenance (a) X-ray equipment (b) Film prcessrs 9 Operatinal Checks 10 Recrds 11 General Regulatry Requirements (a) Acquisitin (b) Supply (c) Dispsal (d) Register f X-ray equipment (e) Cmpliance testing f X-ray equipment (f) Cmpliance testing f premises 12 Incident Respnse and Reprting Radiatin Safety and Prtectin Plan Small Animal Veterinary Diagnstic Radigraphy Page 2 (standard plan)

3 1. Intrductin Fr the purpses f this dcument, the pssessin licensee is identified n page 1 f this dcument. It is a requirement f the Radiatin Safety Act 1999 that reasnable steps are taken t ensure that any persn s health and safety are nt adversely affected by expsure t radiatin. This requirement f the Act will be met if all persns in this practice cmply with this plan. This plan will als: help ensure that the radiatin dses t all persns invlved in the practice are minimised. assist the pssessin licensee in attaining a satisfactry level f cmpliance with the Radiatin Safety Act Scpe This plan is specific t small animal plain film veterinary diagnstic radigraphy prvided in small veterinary practices, and is limited t pssessin licensees perating frm single premises. The acquisitin, prcessing and strage f the images may be traditinal film r digital imaging based. All persns wh are emplyed at this practice will cmply with this plan. These persns will als cmply with the fllwing dcuments: Radiatin Safety Act 1999 and Radiatin Safety Regulatin 2010 ARPANSA RPS 17, Cde f Practice and Safety Guide fr Radiatin Prtectin in Veterinary Medicine (2009) 3. Hazard Assessment Fixed and/r prtable plain film X-ray units are used at this practice. X-ray units present a radiatin hazard when they are being used. Expsure t radiatin is capable f causing injury r fatal illness t a persn. This risk f injury r harm t health depends n the type f radiatin and the extent f the expsure, and might nly be bserved after many years have elapsed. Cnsequently, the expsure f individuals t radiatin must be either prevented r reduced t a level where the risk f adverse health effects is minimal. It shuld be remembered that even lw levels f radiatin dses are still believed t be f sme health risk. Radiatin dses t users, ther emplyees and members f the public will depend n a number f factrs such as the number f expsures, the expsure settings used and wrk practices. The radiatin dses t persns invlved in small animal veterinary diagnstic radigraphy, using fixed r prtable x-ray devices, are relatively lw in cmparisn with thse experienced by persns invlved in sme health related diagnstic prcedures. Hwever, radiatin dse can becme significant as a result f pr wrk practices (eg. if staff repeatedly hld animals withut the use f adequate prtective equipment) r if equipment des nt cmply with the necessary standards (eg. the X-ray beam is nt prperly cllimated during an X-ray expsure). It is imprtant t take care with the expsure factrs used in digital systems as it is pssible t increase expsure t persns invlved in small animal veterinary radigraphy by using higher levels f radiatin than is clinically necessary whilst still btaining diagnstic quality images thrugh sftware based image pst prcessing. Radiatin Safety and Prtectin Plan Small Animal Veterinary Diagnstic Radigraphy Page 3 (standard plan)

4 Digital radigraphy equipment can allw fr significant verexpsure withut awareness by the peratrs invlved. T minimise radiatin verdse hazard, keeping a lg f expsures and retake analysis is recmmended by using the manufacturer s Expsure Index infrmatin. Prvided this plan is cmplied with, and the X-ray units and premises cntinue t meet Radiatin Safety Standards NM003:2010 Standard fr Radiatin Apparatus used t Carry ut Diagnstic Radigraphy f Animals and PR100:2010 Standard fr Premises - Inising Radiatin Surces: the health risk t persns frm the small animal plain film veterinary diagnstic radigraphy practice shuld be minimized t an acceptable level; and there is n requirement fr persnal radiatin mnitring r persnal alarm dsemeters. 4. Functins f the Radiatin Safety Officer This practice has a radiatin safety fficer (RSO) wh has been appinted t: mnitr radiatin safety; reprt t the pssessin licensee abut radiatin safety; and maintain awareness f the radiatin safety legislatin and keep abreast f the trends in radiatin safety. The name f the RSO and cntact details are displayed clse t all X-ray equipment. (a) On-ging RSO duties On an n-ging basis, the RSO: prvides, r arranges training abut radiatin hazards and safe wrking practices checks the X-ray equipment and premises t identify whether cmpliance with Radiatin Safety Standards NM003:2010 Standard fr Radiatin Apparatus used t Carry ut Diagnstic Radigraphy f Animals and PR100:2010 Standard fr Premises - Inising Radiatin Surces has been cmprmised by damage t, r mdificatin f, the X-ray equipment r premises maintains recrds f all X-ray equipment and the lcatins at which it is installed identifies ways f minimising radiatin dses advises staff n safe wrking practices investigates radiatin incidents Additinally, the RSO reprts t the pssessin licensee if sme persn: is invlved in any radiatin incident cntravenes the requirements f this plan r ARPANSA RPS 17, Cde f Practice and Safety Guide fr Radiatin Prtectin in Veterinary Medicine (2009) requires any actin t be taken t achieve cmpliance with this plan r relevant Radiatin Safety Standards (b) Annual RSO duties Each year, the RSO ensures the items belw are checked, recrds the results f these checks in an apprpriate lg bk and ensures that any identified prblems are rectified as sn as pssible: users and all ther emplyees understand, and are cmplying with, this plan the details f each X-ray unit (including its current lcatin) are accurately recrded and match the current inventry attached t the Pssessin Licence the Pssessin Licence is current Radiatin Safety and Prtectin Plan Small Animal Veterinary Diagnstic Radigraphy Page 4 (standard plan)

5 all users f the X-ray equipment hld Use Licences all maintenance and peratinal checks, as required by this plan, are cnducted within the stated timeframes and recrded, and that any relevant prblems have been apprpriately rectified all repairs r mdificatins t the X-ray equipment have been recrded persnal prtective equipment, as required by this plan, is undamaged and readily available cmpliance certificates fr the X-ray equipment and premises have been btained/renewed within the necessary time frames (three and five years respectively). Further infrmatin can be fund at: all recrds required by this radiatin safety and prtectin plan are maintained and kept in a readily accessible lcatin Additinally, if the RSO is nt the same persn as the pssessin licensee, the RSO prvides an annual written reprt t the pssessin licensee. This reprt will include, but nt be limited t, the fllwing: The results f the annual checks stipulated in sectin 4(b). Any cntraventin f this plan r Radiatin Safety Standards NM003:2010 Standard fr Radiatin Apparatus used t Carry ut Diagnstic Radigraphy f Animals and PR100: 2010 Standard fr Premises - Inising Radiatin Surces. The results f a review f this plan t ensure its cntinued effectiveness against actual clinical practice. The effectiveness f, and extent f cmpliance with, this plan. Recmmendatins abut any necessary changes t the plan. 5. Training The RSO will prvide, r arrange fr the prvisin f, apprpriate training t all persns. These emplyees must undertake and satisfactrily cmplete the fllwing training when they start emplyment, and underg annual refresher training thereafter. Participatin at this training is recrded in the training lg bk. (a) Training fr all emplyees A radiatin safety training prgram is prvided t all emplyees. This training prgram addresses the fllwing: Details f this Radiatin Safety and Prtectin Plan, including: Radiatin hazards specific t this practice Specific respnsibilities f each categry f emplyee Regulatry bligatins (b) Additinal training fr users In additin t the abve training fr all emplyees, users will als be prvided specific instructins n: ARPANSA RPS 17, Cde f Practice and Safety Guide fr Radiatin Prtectin in Veterinary Medicine (2009) safe wrk practices, including minimising radiatin dse t animals and users features f, and hw t use, the X-ray equipment selectin f the lwest expsure factrs t achieve the required diagnstic infrmatin Radiatin Safety and Prtectin Plan Small Animal Veterinary Diagnstic Radigraphy Page 5 (standard plan)

6 (c) Additinal training fr persns invlved in image acquisitin Users will als be prvided with initial and refresher training in the fllwing aspects f film prcessing r digital imaging systems: and/r Use f film develper and prcessr Film and imaging screen handling Use f digital imaging systems Sftware and hardware pst prcessing prcedures fr digital images Client and image database management 6. Safe Wrk Practices Users must take reasnable steps t ensure that the radiatin dse received by any persn is as lw as reasnably achievable. T achieve this, the fllwing safe wrk practices must be adhered t at this practice. (a) Use f X-ray equipment General requirements Radigraphy shuld nly be undertaken if justified, i.e., there is a reasnable indicatin fr the prcedure and it can be perfrmed withut undue radiatin hazard t users and staff. All users f the X-ray equipment must hld Use Licences. All use licensees must cmply with the cnditins f the licence issued under the Radiatin Safety Act Only Use Licensees wh are authrised t use the equipment by the pssessin licensee have access t, and are allwed t use, the X-ray equipment. N persn under the age f 16, will be directly invlved in wrk with radiatin. Radigraphy in a dedicated X-ray rm A persn must nt hld any part f the X-ray tube head during radigraphy. Under n circumstances must any persn be expsed t the primary beam. A persn must nt hld the cassette r screen. Cassette/screen hlders must be used whenever a cassette/screen cannt be supprted n a table r n anther supprt. A persn must nt be present in the rm during radigraphy unless their presence is necessary fr the cnduct f the radigraphic examinatin. The primary beam must be restricted t the area t be examined by means f the cllimatr. An animal must nt be held during radigraphy unless, fr clinical reasns, ther means f immbilisatin are nt practicable. Immbilisatin shuld be achieved by mechanical means, tranquilisatin r anaesthesia whenever pssible. The same individual shuld nt be asked t hld animals repeatedly. An examinatin table incrprating apprpriate radiatin shielding will be used. If it is clinically necessary t hld an animal during X-ray examinatins, nly ne persn will be required. Additinally, the persn: (i) (ii) (iii) must nt be under 16 years f age; preferably, shuld nt be pregnant; and must wear persnal prtective equipment. The X-ray tube assembly must be rigidly supprted by a dedicated stand which prvides adequate stability. Radiatin Safety and Prtectin Plan Small Animal Veterinary Diagnstic Radigraphy Page 6 (standard plan)

7 The fastest film/screen cmbinatin, which will ensure a diagnstic quality image, is used. Users must ensure that the apprpriate expsure factrs are used. Expsure settings fr specific examinatins are marked n the X-ray unit. Expsure techniques must nt be adjusted t cmpensate fr inadequate film prcessing. The lwest pssible expsure settings shuld be used in digital systems because the image prcessing sftware is capable f prducing diagnstic quality images even when using expsure factrs lwer than thse used with film. When perfrming radigraphy, the user and assistants must remain behind a prtective screen r, if there is n screen, wear persnal prtective clthing and psitin themselves as far as practicable frm the X-ray tube assembly, the animal and the path f the primary X-ray beam. Drs t the x-ray rm must be clsed during the radigraphic examinatin. Reprting t the RSO Users are required t reprt any cntraventin f this radiatin safety and prtectin plan t the RSO. Users are required t reprt any radiatin incident t the RSO. Persnal prtective equipment and safety devices This practice prvides the fllwing persnal prtective equipment and safety devices: Lead aprns with lead equivalence f at least 0.25 mm are available fr all persns invlved in small animal veterinary radigraphy where they are required t hld an animal fr the cnduct f the examinatin. Lead aprns are t be stred unflded t help prevent the frmatin f cracks. Lead sleeves and glves with lead equivalence f at least 0.5 mm fr all persns invlved in small animal veterinary radigraphy where they are required t hld an animal fr the cnduct f the examinatin. An examinatin table with radiatin shielding equivalent t 0.5 mm f lead n the side and 1.0 mm f lead n the tp. Assrted sandbags and restraints fr animal psitining. Tripds and stands fr the x-ray head and cassette/screen hlders. (b) Register f expsures This practice keeps the fllwing infrmatin abut each expsure: the name f the animal the name f the wner date the radigraphic investigatin is perfrmed particulars f the radigraphic examinatin perfrmed the name f the user f the X-ray equipment Users must ensure that this infrmatin is recrded after each examinatin (including any rejects). Users must ensure that each image is apprpriately labeled either physically r digitally t identify it with the crrect client recrds. This is achieved by marking the radigraph r tagging the digital image with all the infrmatin detailed abve. Users must incrprate the radigraph int the animal s recrds. Fr cnventinal film, the radigraph must be placed int an X-ray sleeve (r envelpe), with the name f the animal and date f expsure written n the sleeve, and fr digital images, the image must be linked t the animal s recrds. Radiatin Safety and Prtectin Plan Small Animal Veterinary Diagnstic Radigraphy Page 7 (standard plan)

8 7. Image Receptrs and Film Prcessing T ensure that radigraphs are f cnsistent diagnstic quality, the fllwing prcedures must be adhered t by all persns invlved in the practice. (a) Digital imaging systems The image receptr must be f an apprpriate size and cmpatible with the X-ray unit. The image receptr will be cleaned daily prir t use. (b) Film sizes and applicatins Films that have passed the manufacturer s recmmended expiry date must nt be used Films must nly be used fr applicatins apprpriate t their size Film must be E speed r faster The crrect Film-Screen cmbinatins must be used t prvide: Reduced expsure factrs and times Reduced mtin blur Reduced repeat examinatins An infrmatin sheet n the selectin f film and intensifying screens is available frm Radiatin Health s website: (c) Strage f unexpsed films & film prcessing chemicals Unexpsed X-ray films must be stred in accrdance with manufacturer s recmmendatins, in a cntainer away frm excessive heat, humidity r chemical cntaminatin (e.g. frm film prcessing chemicals), and adequately shielded against inizing radiatin r in an area remte frm any X-ray unit. Film prcessing chemicals must nt be stred in the same refrigeratr r cupbard as fdstuffs. Dispsal f chemicals will be prvided by an authrised dispsal agent and will cmply with lcal cuncil regulatins. (d) Prcessing f films Manual prcessing f films must be in accrdance with the manufacturer s recmmendatins and must satisfy the fllwing requirements: Temperature f develping slutins must be measured An apprpriate time-temperature chart must be used t determine prcessing time The time f prcessing must be measured The cncentratins f develping slutins must be in accrdance with the manufacturer s specificatins. Prcessing f films will be in accrdance with Annex G, Guide t Manual Prcessing f Radigraphs, ARPANSA RPS 17 Safety Guide fr Radiatin Prtectin in Veterinary Medicine (2009). Radiatin Safety and Prtectin Plan Small Animal Veterinary Diagnstic Radigraphy Page 8 (standard plan)

9 8. Repair and Maintenance Repair and maintenance is cnducted n the X-ray equipment, film prcessrs and digital imaging systems t ensure that images are prduced with ptimal diagnstic quality and that radiatin dses cntinue t be minimised. Recrds f all repair and maintenance cnducted at this practice are kept in the equipment maintenance lg bk. (a) X-ray equipment All maintenance must be carried ut in accrdance with the schedule specified by the manufacturer. Maintenance and repairs must be cnducted by a qualified service persn. If the equipment is t be used (i.e. energised) during repair and maintenance, the radiatin safety fficer must ensure that the persn hlds a licence t use X-ray equipment fr maintenance, repair r cmmissining. Fllwing the repair f an X-ray unit, the radiatin safety fficer must ensure that the unit cntinues t cmply with Radiatin Safety Standard NM003:2010 Standard fr Radiatin Apparatus used t Carry ut Diagnstic Radigraphy f Animals, this may necessitate having the equipment tested fr cmpliance with this standard by an accredited persn. (b) Film prcessrs Autmatic prcessr All maintenance must be carried ut in accrdance with the schedule specified by the manufacturer. The prcedures detailed in the manufacturer s peratin manual must be fllwed. These prcedures will be perfrmed by an apprpriately trained persn authrised by the pssessin licensee. Majr prcessr repairs and rutine service must be handled by a qualified service persn. Manual prcessing Cleaning the prcessing and develping tanks, and replacing the chemicals at least every tw weeks, will ensure cnsistent diagnstic quality images are prduced. The maintenance prcedure is displayed in a prminent lcatin adjacent t the prcessing equipment. This prcedure will be perfrmed by a persn trained t perfrm this wrk and wh has been authrised by the pssessin licensee. 9. Operatinal Checks The peratinal checks detailed in the table belw are t be perfrmed by persns trained t carry ut this wrk and have been authrised by the pssessin licensee. Any identified prblems are t be reprted t the radiatin safety fficer and the pssessin licensee. Prblems will be rectified and, if necessary, equipment and premises will be re-certified against the relevant standards. Results f all peratinal checks are t be recrded in the peratinal check lg bk. Weekly Frequency Operatinal Check Check the quality f a test film/digital image (e.g. first clinical image f the day) by cmparing it with a reference radigraph Check quantity and quality f chemicals in prcessrs, and replenish/replace as required by manufacturer s specificatin Radiatin Safety and Prtectin Plan Small Animal Veterinary Diagnstic Radigraphy Page 9 (standard plan)

10 Mnthly Frequency Six mnthly Operatinal Check Perfrm a retake/reject analysis t determine the reasn fr the retake r reject (which may include prblems with the film, develping prcess, the X-ray unit r the user) Check the cnditin f persnal prtective equipment and safety devices Check that expsure factrs fr specific examinatins are readily available Check that the RSO details are displayed in a prminent lcatin n r near all X-ray equipment and are crrect Check that X-ray equipment warning signs are displayed n each cntrl panel and are in gd cnditin Check that the darkrm and/r prcessing bx is free frm light leaks and that safelights are adequate Check the cleanliness f the intensifying screen Check that the X-ray film is stred in accrdance with this plan Check that the ldest X-ray film is used first Check that film is within the expiry date specified by the manufacturer Check that the fastest film and film/intensifying screen cmbinatin, which will ensure a diagnstic quality image, is used Check that the prcessr maintenance prcedures are displayed in a prminent lcatin adjacent t the film prcessr Check that instructins fr mixing chemicals and prcessing films are available Check that a time/temperature chart, a timer and a thermmeter are available fr manual prcessing Check that the prcessr shws n sign f leakage r chemical build up, and the tanks, rller racks, crssvers and splash guards are free frm grime Check that the replenishing tanks are at the crrect level and shw n sign f leakage 10. Recrds The fllwing recrds are maintained, and are kept in a readily accessible lcatin: Current Pssessin Licence issued under the Radiatin Safety Act 1999 Current radiatin safety and prtectin plan apprved by the Chief Executive, Qld Department f Health Annual reprts by the radiatin safety fficer Apprvals t acquire r relcate the X-ray equipment X-ray equipment dispsal recrds Inventry and lcatin f X-ray equipment Training lg bk Equipment maintenance lg bk Operatinal check lg bk Register f examinatins perfrmed Radiatin safety audit reprts Incident reprts Radiatin Safety and Prtectin Plan Small Animal Veterinary Diagnstic Radigraphy Page 10 (standard plan)

11 11. General Regulatry Requirements This sectin utlines the legislative requirements assciated with the mvement r change f wnership f X-ray equipment, and testing f the X-ray equipment and the premises in which it is used. It is the respnsibility f the pssessin licensee t ensure the necessary apprvals are granted prir t the fllwing cnsideratins. (a) Acquisitin An X-ray unit must nt be acquired unless that persn has btained an Apprval t Acquire that specific X-ray unit. (b) Supply Within Queensland An X-ray unit must nt be supplied (sld, lent, exchanged etc) t anther persn in Queensland, unless that persn has btained an Apprval t Acquire that specific X-ray unit. Outside Queensland (relcatin) An X-ray unit must nt be relcated (mved, sld, lent, exchanged etc) utside f Queensland, unless an Apprval t Relcate has been btained fr that specific X-ray unit. The Chief Executive, Queensland Department f Health must be ntified within 7 days after it s relcatin. (c) Dispsal T dispse f X-ray equipment, the X-ray unit must be rendered permanently incapable f prducing X-rays. Fllwing this, the pssessin licensee must give the Chief Executive, Queensland Department f Health written ntice f the dispsal within 7 days f the dispsal. (d) Register f X-ray equipment An inventry f X-ray equipment in pssessin f the pssessin licensee, including its current lcatin, must be maintained by the pssessin licensee. The Radiatin Health Unit shuld be ntified abut any change f lcatin (rm number change, physical address etc) f an X-ray unit. (e) Cmpliance testing f X-ray equipment Befre initial use, and every three years thereafter, the X-ray equipment must be assessed, by an apprpriately accredited persn, fr cmpliance with Queensland s Radiatin Safety Standard NM003:2010 Standard fr Radiatin Apparatus used t Carry Out Diagnstic Radigraphy f Animals. Only equipment which has a certificate f cmpliance may be used. (f) Cmpliance testing f premises Befre initial use, and every five years thereafter, each rm where X-ray equipment is used must be assessed, by an apprpriately accredited persn, fr cmpliance with Queensland s Radiatin Safety Standard PR100: 2010 Standard fr Premises - Inising Radiatin Surces. Only premises which have a certificate f cmpliance may be used. Additinally, if there has been a change in the lcatin f X-ray equipment (including its lcatin within a rm), wrklad r use f an adjacent rm, the pssessin licensee must ensure that an Radiatin Safety and Prtectin Plan Small Animal Veterinary Diagnstic Radigraphy Page 11 (standard plan)

12 apprpriately accredited persn perfrms an assessment f the premises fr cmpliance with the relevant Radiatin Safety Standard, befre the equipment is used. 12. Incident Respnse and Reprting A radiatin incident is an incident adversely affecting, r likely t adversely affect, the health r safety f any persn because f the emissin f radiatin. This includes any near misses. All radiatin incidents are t be reprted t the RSO. A written incident reprt is t be prduced by the RSO and submitted thrugh the pssessin licensee t the Radiatin Health Unit within 7 days f the ccurrence f an incident. This reprt will include: incident descriptin including details f the X-ray equipment invlved and its lcatin. estimates f radiatin expsure t individuals (if applicable). actin taken. prpsals t prevent a recurrence. Additinally, if the incident includes any f the fllwing events, the pssessin licensee must immediately ntify the Chief Executive, Queensland Department f Health, either rally r in writing. If the ntificatin was prvided rally, a written ntificatin must be submitted within 7 days. The surce is, r appears t have been, lst r stlen. Equipment that uses, measures r cntrls radiatin emitted frm the surce malfunctins with the result, r likely result, that there is, r will be, an unintended emissin f the radiatin r a persn is, r will be, unintentinally expsed t the radiatin. The fllwing details the prcedures that are t be fllwed in the event f the specified incident: Prcedures in the event f actual r suspected malfunctin f the X-ray equipment causing an unintended expsure t any persn In this case, the fllwing prcedure must be bserved: The user must switch ff the X-ray unit as quickly as pssible at the main supply. The user must take precautins t prevent the use f the X-ray unit by: psting a sign which states that the X-ray unit must nt be used remving the key t the X-ray unit, r taking ther apprpriate actin. The user must advise the RSO f the incident. The X-ray unit must nt be used until it has been repaired (and if necessary cmpliance tested) and the pssessin licensee has authrized its use. The RSO must determine the radiatin dse t each persn invlved in the incident. Radiatin Safety and Prtectin Plan Small Animal Veterinary Diagnstic Radigraphy Page 12 (standard plan)