PROCEDURES FOR PERSONAL DOSIMETRY TO ENSURE COMPLIANCE WITH THE IONISING RADIATIONS REGULATIONS 1999 Manager responsible Claire Skinner, Head of Radiological Physics and Radiation Safety Date published September 2007 Reviewed February 2008 Next review date February 2009 Approved by Radiation Protection Committee Ionising Radiation Safety Policy Related policies Procedures for the use of Radiation Local Rules Date policy impact assessment carried out September 2007 Result of policy impact assessment Race: Not equality relevant Disability: Not equality relevant Age: Not equality relevant Gender: Not equality relevant Religion /belief: Not equality relevant Sexual orientation : Not equality relevant Version control 2.0
Statement regarding equality impact assessment We welcome feedback on this policy and the way it operates. We are interested to know of any possible or actual adverse impact that this policy may have on any groups in respect of race, disability, gender, sexual orientation, age, religion/belief or other characteristics. The person responsible for equality impact assessment for this policy is Claire Skinner. This policy has been screened to determine equality relevance for the following equality groups: race, disability, age, gender, sexual orientation, religion/belief. The policy is considered to have little or no equality relevance in itself, but is a tool for highlighting and promoting equality assessment. 2
Contents Page Introduction 4 Responsibilities and duties of staff 4 Procedures for issuing and returning dose monitors 8 Procedures for escalating non-return or non-collection of badges 10 Procedures for reporting dose results 12 Procedures fir investigating doses which may exceed investigation levels 13 3
PROCEDURES FOR PERSONAL DOSIMETRY ENSURING COMPLIANCE WITH THE IONISING RADIATIONS REGULATIONS 1999 INTRODUCTION Applies to: All staff issued with dose monitors Clinical Directors, Clinical Leads, General Managers Operational Managers/Superintendent Radiographers Badge Coordinators Radiation Protection Supervisors Head of Radiological Physics and Radiation Safety Dosimetry Service Manager Radiation Protection Adviser These procedures describe the arrangements which are necessary for the trust to ensure compliance with the Ionising Radiations Regulations 1999 (IRR99) regarding Personal Dosimetry. Local procedures may exist in different working areas for some of the arrangements covered by this procedure. If this is the case these local procedures must be documented and made available to all staff who need to know about them; and must be sufficiently robust to satisfy the requirements of this procedure. RELEVANT DOCUMENTS Trust Ionising Radiation Safety Policy The Ionising Radiations Regulations 1999 RESPONSIBILITIES AND DUTIES OF STAFF The trust s Ionising Radiation Safety Policy outlines the responsibilities of managers and staff. In this procedure, responsibilities and duties relating specifically to personal dosimetry are described. Clinical Directors & General Managers To ensure that there are arrangements for ensuring that the division of responsibilities set out in this document are identified and are made known to all staff to whom they apply. To ensure that local procedures are in place where necessary in order to satisfy the requirements of this document, and that these local procedures are brought to the attention of all staff to whom they apply. 4
To provide support to the Radiation Protection Supervisor(s) (RPSs) in their area in ensuring good supervision of compliance with the Local Rules. This includes support for ensuring that personal dose monitors are used correctly by all staff working in Controlled or Supervised areas. To take action in preventing any breach of IRR99 or the trust s Ionising Radiation Safety Policy. This includes ensuring that an investigation takes place when personal dose monitors are persistently not worn or not returned on time; or when personal doses persistently exceed the trust s Dose Investigation Levels (DILs). To escalate persistent non-compliances to the Medical Director when an individual continues to fail to comply and this cannot be dealt with locally. This may ultimately lead to disciplinary action and suspension from further work with radiation. Clinical Leads & Operational Managers/Superintendent Radiographers/Other Line Managers Where authority has explicitly been delegated, line managers will, within defined areas, carry some or all of the responsibilities identified above for Clinical Directors and General Managers. For example: To ensure that local procedures are in place where necessary in order to satisfy the requirements of this document, and that these local procedures are brought to the attention of all staff to whom they apply. To provide support to the Radiation Protection Supervisor(s) (RPSs) in their area in ensuring good supervision of compliance with the Local Rules. This includes support for ensuring that personal dose monitors are used correctly by all staff working in Controlled or Supervised areas. To escalate persistent non-compliances to the General Manager, Clinical Director or Medical Director when an individual continues to fail to comply and this cannot be dealt with locally. This may ultimately lead to disciplinary action and suspension from further work with radiation. The Operational Manager also has responsibility: To ensure that appropriate personal dose monitors are available to all staff who require them and who work in Controlled or Supervised areas. To ensure that all radiation work is conducted in accord with the Local Rules. This includes ensuring that personal dose monitors are issued to, worn by and returned promptly by all these staff. To escalate any persistent failure to wear or return dose monitors to the Clinical Director, Clinical Lead or General Manager To review personal dose monitoring results each month as soon as practicable after they are made available. To investigate and take appropriate action when DILs are exceeded. To report to the Radiological Physics and Radiation Safety Group (RPRSG) if a member of staff declares their pregnancy To take appropriate action when it is suspected that a member of staff has received an overexposure. To make the following staff appointments: 5
a nominated deputy to carry out the responsibilities listed above (appointed in conjunction with the GM) a Badge Coordinator for each Controlled or Supervised Area a Deputy Badge Coordinator for each Controlled or Supervised Area to cover for when the badge coordinator is absent during the badge changeover period Badge Coordinators The Operational Manager will delegate the following tasks to the Badge Coordinator and their deputy: To coordinate personal dose monitors according to the document Responsibilities of radiation monitoring badge coordinators (available from the Radiological Physics and Radiation Safety Group (RPRSG)) To collect and distribute personal dose monitors To advise monitored staff on the correct wearing of personal dose monitors To notify the RPRSG of new (or returning) radiation workers staff leavers (or those no longer working with radiation) a radiation worker who declares her pregnancy lost, damaged or inadvertently exposed badges To inform the operational manager if they are to be absent during the badge changeover period Radiation Protection Supervisors To supervise work with ionising radiation in order to ensure that it is carried out in accordance with the Local Rules. This includes supervising the correct use of personal dose monitors by staff. The RPS may undertake some or all of the roles listed above for Managers and Badge Coordinators, if they are the same person. These roles are not however part of their direct remit as RPS. In practice it will be beneficial to involve the RPS in reviewing dose results and conducting investigations into doses which exceed DILs, since the RPS is closely involved with radiation work in their area on a daily basis, e.g. Senior Nuclear Medicine Technologist. However, responsibility for these tasks remains with the line manager, (in the case of Superintendent Radiographers these are the same person). Head of Radiological Physics and Radiation Safety To appoint a Dosimetry Service Manager. To review doses received by staff monitored by the Approved Dosimetry Service (ADS) on a monthly basis. To support the investigation of doses which exceed DILs in conjunction with the aforementioned. 6
Dosimetry Service Manager To ensure that personal dose monitors are distributed to Badge Coordinators after they have been received from the ADS To ensure personal dose monitors that have been returned to the RPRSG are forwarded to the ADS To ensure that dose results are circulated when they are received from the ADS To ensure that a central record is kept of doses received by staff monitored by the ADS To ensure that the ADS is contacted if timescales agreed with the ADS are not met for the timely issue of monitoring badges and dose records To inform the Head of the RPRSG or the RPA when a dose exceeds a DIL Radiation Protection Adviser To advise the Trust Board on issues concerning compliance with IRR99. This includes providing advice regarding mechanisms for ensuring that the trust s personal dosimetry procedures are compliant with IRR99. All Employees Issued with Dose Monitors To wear and return their personal dose monitors as instructed by their RPS and/or local badge coordinator according to local procedures. Failure to comply with procedures may result in disciplinary action. To report to their line manager or RPS if they suspect that they or any other person may have received an overexposure. To report to their badge coordinator if they suspect that their personal dose monitor may have been inadvertently exposed, or if it has been lost or damaged To declare their pregnancy to their line manager. If for any reason an employee does not wish to formally declare their pregnancy to their line manager, they are encouraged to inform the RPRSG Dosimetry Service who will keep this information in confidence. 7
PROCEDURES FOR ISSUING AND RETURNING DOSE MONITORS The new month s issue of personal dose monitors for the trust should be received by the RPRSG from the ADS before the end of the previous month. If the new issue is not received by the 25 th day of the previous month, the Dosimetry Service Manager will ensure the ADS is contacted and that they take steps to ensure monitors are delivered. The Dosimetry Service Manager will make arrangements to ensure that the new month s issue of dose monitors is sent to each Badge Coordinator by the 1 st day of the month. Each new issue will be accompanied by an issue form listing all monitored staff; fields for individual members of staff to sign and date when they both collect and return their personal dose monitors; a field for the Badge Coordinator to sign indicating that they have received the personal dose monitors; and a field for comments. The new personal dose monitors should be distributed to staff according to local procedures which suit working practice in each area. Each member of staff collecting their new personal dose monitors should sign and date the new month s issue form. The previous month s personal dose monitors should be collected according to local procedures which suit working practice in each area. The previous month s issue form should be signed and dated by each member of staff returning their dose monitor. The Badge Coordinator should also sign to indicate that they have received the returned dose monitor. The Badge Coordinator may add comments, e.g. if the dose monitor has been lost, damaged, or if it is unavailable for any other reason. When all available personal dose monitors have been collected from the previous month, the Badge Coordinator should take copies of the previous month s issue form and circulate these as follows: one copy to the RPRSG along with the returned personal dose monitors one copy to each of the managers listed on the form (local procedures may include different managers for medical and non-medical staff) retain the original This should be done by the 5 th working day of the month AT THE LATEST. If some personal dose monitors have not been returned by this date, the Badge Coordinator MUST inform the appropriate manager, but must not delay in returning those dose monitors which have been returned. The Badge Coordinator should make reasonable efforts to ensure that personal dose monitors are returned, but all monitored staff must be aware that it is their personal responsibility to ensure that they return their dose monitors on time. This includes returning the monitor in advance if they are going on leave during the badge changeover period. it is their personal responsibility to wear their dose monitors whenever they are working in a Controlled or Supervised Area it is their personal responsibility to inform the Badge Coordinator if they have lost or damaged their dose monitors or if they are unable to return them for any other reason. 8
If any dose monitors are returned later than this, the Badge Coordinator should amend the retained original issue form, take copies and forward the dose monitors and issue forms as described previously. The Dosimetry Service Manager will ensure the first set of received dose monitors are returned to the ADS by the 8 th working day of the month. A second return to the ADS will be made during the third week of the month for any dose monitors received in the intervening period. Any dose monitors received after this will be returned with the next month s dose monitors. The Dosimetry Service Manager will ensure that the issue and return details stated on the form are entered into the dosimetry database. 9
PROCEDURES FOR ESCALATING NON-RETURN OR NON-COLLECTION OF BADGES When the completed issue form is received by the appropriate manager(s) from the Badge Coordinator, the appropriate operational manager(s) must ensure that they review the form in order to determine whether any dose monitors have not been collected or returned by the user without a valid reason. If any dose monitors have not been returned, or have not been collected at issue, and no valid explanation has been given, the operational manager must carry out an investigation with appropriate support. Single non-return or non-collection: If it is the first time during the current calendar year that a member of staff has failed to return their dose monitor, or has not collected their dose monitor at issue, the manager should discuss with the individual concerned to establish the reason for the non-compliance, confirm the individual s personal responsibilities under this procedure, and if possible to ensure the dose monitor is returned. The manager should document the outcome of the investigation and inform the RPRSG. If it is not possible for the dose monitor to be returned (e.g. if it has been lost) the RPRSG may make a charge to the department concerned. Multiple non-return or non-collection: Managers will receive information regarding the issue and return status of personal dose monitors for all monitored staff in their area for the current calendar year when they receive the dose results. This information will assist the manager in determining which of their staff have not either collected or returned their dose monitors over the year and on how many occasions. If an individual has failed to return their dose monitor, or has not collected it at issue, on 3 occasions within that calendar year, the manager should discuss with the individual concerned to establish the reason for the non-compliance, confirm the individual s personal responsibilities under this procedure, and if possible to ensure the dose monitors are returned where relevant. Furthermore, the manager should inform the Clinical Lead, Clinical Director or General Manager (depending on the line management structure for the member of staff) who should then conduct an immediate investigation into why dose monitors have persistently not been returned or collected, together with the line manager, and inform the RPRSG of the outcome. Continuing persistent failure to comply: If the individual continues to fail to return or collect their dose monitor following this investigation, the Clinical Lead, Clinical Director or General Manager will escalate to the Medical Director who will inform the RPRSG of the outcome. This may ultimately lead to disciplinary action and suspension from further work with radiation. A report regarding persistent offenders will be presented at the trust s Radiation Protection Committee meeting by the RPRSG. 10
SUMMARY: Single non-return or non-collect: Operational Manager or Clinical Lead investigates 3 non-returns or non-collects within calendar year: Escalate to General Manager or Clinical Director More than 3 non-returns or non-collects: Escalate to Medical Director 11
PROCEDURES FOR REPORTING DOSE RESULTS Dose results should be received by the RPRSG from the ADS within 14 days of receipt of the dose monitors by the ADS. If dose results are not received within 21 days of the dose monitors being sent from the RPRSG, the Dosimetry Service Manager will ensure that the ADS is contacted and take steps to ensure that the dose results are delivered. On receipt of the dose results from the ADS, the Dosimetry Service Manager will make arrangements to ensure that the results are distributed to the following staff: the appropriate manager of each area (local procedures may include different managers for medical and non-medical staff) the RPS for each area the Head of the RPRSG The Dosimetry Service Manager will also ensure that information regarding the issue and return status of dose monitors for the current calendar year, together with a summary of that year s doses, accompanies the dose results. On receipt of the dose results from RPRSG the manager will review the doses as soon as is practicable. If the manager is absent from work they should ensure that this task is carried out by their nominated deputy. The manager must investigate any doses which exceed formal or local DILs according to the procedure described in this document. The appropriate manager must also investigate dose trends, e.g. if a member of staff s doses have started to increase even though they have not yet exceeded a DIL. 12
PROCEDURES FOR INVESTIGATING DOSES WHICH EXCEED INVESTIGATION LEVELS The trust s Annual Dose Investigation Levels (DILs) are set out in the trust s Ionising Radiation Safety Policy. In practice it is helpful to establish Monthly DILs against which monthly dose results can be compared. The trust s DILs are as follows: Dose quantity Annual DIL (msv) Monthly DIL (msv) Effective (whole body) dose, Hp(10) 3 0.5 Eye dose, Hp(0.3) 20 3.75 Skin or extremity dose, Hp(0.07) 75 12.5 The purpose of DILs is to trigger a review of working conditions in order to ensure that exposure is being restricted as far as is reasonably practicable. Managers may set local DILs if they wish, provided that these are set lower than the formal trust Investigation Levels, and may have local procedures for investigating them. The DILs must be included in the Local Rules. The RPRSG will present a summary of all doses investigated at the trust s Radiation Protection Committee. Single dose which exceeds a DIL If any dose result exceeds the trust s monthly DIL the Dosimetry Service Manager will immediately inform the Head of the RPRSG or the RPA. The Head of the RPRSG or the RPA will arrange for the following staff to be informed immediately: the member of staff who has exceeded the Investigation Level the line manager of that person The Head of the RPRSG or the RPA will nominate a suitable person from the RPRSG to assist and support the line manager with their investigation and will inform the manager who that person is. The line manager will undertake an immediate investigation into the circumstances with the assistance of the RPRSG and the RPS. This investigation may include: a detailed discussion with the individual regarding their working practices during the period concerned comparisons of dose and working practices with other staff carrying out similar work a review of any other monitoring carried out in the areas concerned, where relevant (e.g. environmental monitoring) results of any special radiation surveys in the areas concerned to identify any deterioration in the physical control measures evidence about the involvement of the individual in any known incidents in which they may have received an unusual exposure 13
a review of whether the Local Rules are being followed evidence from the RPS, individual concerned and work colleagues about adherence to Local Rules or deficiencies in those rules in the light of changes to working practices The manager will ensure that a report of the investigation is written, in conjunction with the member of staff from the RPRSG. The investigation should normally produce firm conclusions about the need for further control measures or better application of controls. The manager will keep a copy of the investigation report and send a copy to the RPRSG. The manager will ensure that appropriate action is taken resulting from the recommendations made in the investigation report. Multiple doses which exceed a DIL If dose results exceed the trust s monthly DIL on 3 occasions in any one calendar year, OR the cumulative dose for that year exceeds the trust s annual DIL, AND the individual is not designated as a Classified Worker under IRR99, The Dosimetry Service Manager will immediately inform the Head of the RPRSG or the RPA. The Head of the RPRSG or the RPA will initiate an investigation as set out above, but in addition will inform the Clinical Lead, Clinical Director or General Manager. The Clinical Lead, Clinical Director or General Manager will participate in the investigation which will include all the elements described above and additionally focus on the need for a major review of working practices and workloads the need to designate the member of staff as a Classified Worker under IRR99, and if so, the necessary steps to be taken Doses persistently exceed DILs and individual remains unclassified If dose results exceed the trust s monthly DIL on 6 occasions in any one calendar year, AND the individual remains unclassified, the Dosimetry Service Manager will immediately inform the Head of the RPRSG or the RPA. The Head of the RPRSG or the RPA will initiate an investigation as set out above, and in addition will inform the Clinical Lead, Clinical Director or General Manager. 14
The Clinical Lead, Clinical Director or General Manager will participate in the investigation which will include all the elements described above and additionally focus on the urgent need to designate the member of staff as a Classified Worker under IRR99 and the necessary steps to be taken further major review of working practices and workloads, if the member of staff is to continue working with radiation whether the member of staff should be prevented from carrying out further work with radiation Doses exceed the limit for a classified worker OR an annual dose limit In normal circumstances, if the above procedures are followed it is unlikely that the limit for a classified worker (if the individual is unclassified) or an annual dose limit will be exceeded. However, if this does occur the Dosimetry Service Manager will immediately inform the Head of the RPRSG or the RPA. The Head of the RPRSG or the RPA will immediately inform: the over-exposed individual the Clinical Lead, Department Head or Operational Manager the Clinical Director or General Manager the Risk and Safety Manager the Lead Occupational Health Consultant The Clinical Lead, Department Head or Operational Manager will ensure that an incident form is completed. The RPA or Head of the RPRSG will provide advice on the steps that need to be taken, which may include informing the Health and Safety Executive if a dose limit has been exceeded a medical assessment of the individual by a doctor appointed under IRR99 preventing the individual from further work with radiation a formal investigation under IRR99 The Clinical Director or General Manager will ensure that the advice provided by the RPA or Head of the RPRSG is followed. 15
PROCEDURES FOR INVESTIGATING SUSPECTED OVEREXPOSURES FOLLOWING AN INCIDENT All employees must report to their line manager or RPS if they suspect that they or any other person may have received an overexposure. If the RPS is informed, the RPS must immediately report the incident to the member of staff s line manager (if they are not that person). The line manager must ensure that an incident form is completed immediately, including all relevant information and exposure factors, and forward the incident form to the local area coordinator. The line manager will inform the RPA or the Head of the RPRSG of the incident and provide them with a copy of the incident form, so that the dose and risk can be assessed. The line manager will contact the Dosimetry Service Manager and request an emergency readout of the overexposed individual s dosemeter. If the dose assessment indicates that the individual may have received a dose greater than a DIL, and investigation should be carried out following the procedure given in this document. 16