Section II: Radiation
Safety Guidelines for the
Human Use of
Radionuclides.
1: Radiation Safety
Program
Responsibilities
Authorization
Nursing Procedures
Use of Radiation
Sources
2: Procedures and Nursing Instructions
General Procedures
Brachythrapy
Radiopharmaceutical
Therapy
Appendix A
Emergency Procedures
Radiation Safety Call
List
 |
|
| Services: |
|
 |
Biological
Safety |
 |
Chemical
Safety |
 |
EHOS |
 |
Fire
Safety |
 |
Radiation
Safety |
|
Resources: |
|
|
|
|
CHAPTER ONE
RADIATION SAFETY PROGRAM
RESPONSIBILITIES
HUMAN USE OF THERAPEUTIC
RADIATION SUBCOMMITTEE
The Subcommittee members appointed to this body are the following:
- Medical Director, Georgia Radiation Therapy Center
- Radiation Safety Officer
- MCG Hospital Administration Representative
- MCG Hospital Nursing Representative
- University Hospital Administrator or Nursing Representative
- St. Joseph Hospital Administrator or Nursing Representative
- VA Medical Center Administrator or Nursing Representative
- Georgia Radiation Therapy Center Physicist
The Subcommittee sets policies and establishes procedures for the safe use of therapeutic radiation sources at the hospitals described in the preamble. The Subcommittee is charged with developing radiation safety policy in such a manner as to: (1) assure compliance with all federal, state, and local regulations, (2) maintain exposures as low as reasonably achievable for both radiation workers and the general public, and (3) facilitate use of therapeutic procedures involving radiation sources when documentation of experience and training is presented along with sufficient equipment and acceptable protocol to justify the use of these materials. The Subcommittee will meet as often as necessary to carry out its functions. The Subcommittee will render decisions in its specific area of authority. Uses of radioactive material may be approved provided that greater than 50% of the Subcommittee members respond and a majority of the respondents are affirmative. In any Subcommittee member has reservations about a protocol, the member may request that the protocol be acted upon by the Radiation Safety Committee.
This Subcommittee is authorized to approve specific physicians to use radiation sources in therapeutic procedures. Therapeutic procedures involving the use of radionuclides must be performed either by or under the direct supervision of an approved physician or, at the discretion of the Medical Director of Radiation Therapy, by a radiation therapy resident in training.
RADIATION SAFETY OFFICE
The Radiation Safety Office encompasses the personnel and resource facilities necessary for the Radiation Safety program. The Radiation Safety Office provides many radiation protection services such as personnel monitoring, waste disposal, radiation safety surveys, maintenance of records required by the State, and consultation on the safe use of radiation sources. The Radiation Safety Office is budgeted through the Office of Business Operations which is also responsible for the staffing of that office
RADIATION SAFETY OFFICER
The Radiation Safety Officer is responsible for radiation protection for any licensed activity under the authority of the Therapy Subcommittee. This responsibility includes general surveillance of overall activities and areas in which radiation sources are used, determination of compliance with rules and regulations, authorization conditions and the conditions of project approval specified by the Subcommittee, consultation on radiation protection with staff, determination of the need for and evaluation of personnel monitoring, conduction of instructional programs to train personnel in safe procedures in the use of radiation sources, and termination of any project that is found to be a significant risk to health or property. The Radiation Safety Officer is appointed by the President of MCG upon the recommendation of the Chairman of the Radiation Safety Committee. The Vice President for Fiscal Affairs and Planning is responsible for providing the liaison between the office of the President, the Radiation Safety Committee, and the RSO.
All applications for radiation source use, location, procedures and possession limit changes are reviewed by the Radiation Safety Officer. The Radiation Safety Officer recommends final action on applications to the Subcommittee.
AUTHORIZED USERS
ROUTINE USE OF THERAPEUTIC SOURCES
The Georgia Department of Natural Resources has established acceptable training and experience criteria for physicians licensed to use radionuclides for therapeutic procedures in the practice of medicine. These criteria will be utilized to evaluate physician requests to be authorized to perform well-established procedures.
NON-ROUTINE USE OF THERAPEUTIC SOURCES
In instances where an investigator desires to use therapeutic sources of radionuclides in a research protocol, the investigator must provide substantial information to the Subcommittee so that proper evaluation of the proposal can be made. To perform a procedure for which a “Notice of Clinical Investigational Exemptions for a New Drug" (IND) has not been accepted by the Food and Drug Administration, the Radioactive Drug Research Committee must grant approval to the proposal before authorization can be reviewed by the Subcommittee.