Non-ionising Radiation Safety (Lasers) Operating Policy Type: Policy Register No: 14020 Status: Public Developed in response to: Control of Artificial Optical Radiation at Work Regulations 2010 Contributes to CCQ Core Outcome 4 Consulted With Post/Committee/Group Date Andrea Francis Governance/Clinical Lead Radiology July 2014 Linda Chilton Laser Protection Supervisor Surgical care Practitioner July 2014 Adele Wisbey Head of Nursing July 2014 CA Lewis Radiation Protection Advisor July 2014 M Fitzgerald Radiation Protection Advisor July 2014 Professionally Approved by: Technically Approved by: Health & Safety Group E Chaloner, Clinical Scientist Radiation Protection King s College Hospital 19 August 2014 Version Number 1.0 Issuing Directorate Radiology Ratified by: Document Ratification Group Ratified on: 28th August 2014 Trust Executive Sign Off Date September 2014 Implementation Date 1st September 2014 Next Review Date July 2017 Contact for Information Andrea Francis, Radiology Governance/Clinical Lead Policy to be followed by (target staff) All Trust staff who work with or are involved in work with non-ionising radiations Distribution Method Intranet & Website Related Trust Policies (to be read in conjunction with) Risk Management Strategy and Policy Health and Safety Policy Health & Safety Policy Radiation Safety Management: Ionising and Non Ionising Radiations, Radioactive S b d M di l R di i Document Review History Review No Reviewed by Review Date 1
Contents 1. Purpose 2. Introduction 3. Scope 4. Commencing Work with Non-ionising Radiations 4.1 Prior notification to the Laser Protection Adviser (LPA) 4.2 Prior risk assessment 4.3 Designation of areas 4.4 Laser Protection Supervisor (LPS), local rules and contingency plans 4.5 Prior authorisation and training 5. Staff Responsibilities 6. Use of Personnel Protective Equipment (PPE) 6.1 Duties of staff 6.2 Labelling and checking PPE 7. Management of Radiation Equipment 7.2 Selection of equipment 7.3 Routine Performance Testing and audit 7.4 Maintenance 8. Training 9. Monitoring & Auditing 10. Communications and Implementation 11. Equality & Diversity 12. References 2
1. Purpose 1.1 The purpose of this document sets out requirements for the Trust Procedures for Nonionising Radiation Safety for all staff who use or who are involved in the use of sources of electromagnetic radiation in the wavelength range between 100 nm and 1 mm, hereafter termed non-ionising radiation, on Trust premises. 2. Introduction 2.1 The Trust has implemented the following levels of documentation to ensure compliance with legislative requirements regarding radiation safety: Level 1: Level 2: Policy on Radiation Safety Management Trust-wide Procedures entitled: Trust Procedures for Ionising Radiation Safety Trust Procedures for Non-ionising Radiation Safety Trust Procedures for the Control of Radioactive Substances. Trust Procedures for Medical Exposures (excluding Community Special Care Dentistry) Trust Procedures for Medical Exposures (Community Special Care Dentistry only) Level 3: Departmental Instructions including: Departmental Local Rules that are the key safety instructions for staff and visitors Departmental Standard Operating Procedures or Protocols that set out the way in which work with radiation is carried out or how clinical diagnosis or treatment is undertaken Level 4: Departmental Records: 2.2 These procedures, in conjunction with Departmental Local Rules and Standard Operating Procedures and Records, aim to address the requirements of the following legislation and guidance. HMSO. Control of Artificial Optical Radiation at Work Regulations, 2010 SI 2010 No. 1140. [http://www.legislation.gov.uk/uksi/2010/1140/pdfs/uksi_20101140_en.pdf]. BS EN 60825-1:1994. Safety of laser products Part 1: Equipment classification, requirements and user s guide BS EN 60825-8:1999. Safety of laser products Part 8: Guidelines for the safe use of medical laser equipment BS EN 60825-14:2004. Safety of laser products Part 14: A user s guide BS EN 207:2009. Personal eye-protection equipment. Filters and eye-protectors against laser radiation (laser eye-protectors) MHRA DB2008(03) April 2008. Guidance on the safe use of lasers, intense light source systems and LEDs in medical, surgical, dental and aesthetic practices 2.3 The Laser Protection Adviser, supported by the Radiation Protection Service, fulfils other regulatory requirements on behalf of the Trust in accordance with their own Standard Operating Procedures. 3
3. Scope 3.1 This policy covers the use of Lasers, Intense Pulsed Light Sources (IPLs), Ultra-violet (UV) and blue light sources, dental curing lights and other intense light sources. 3.2 This document applies to all Trust staff who work with or are involved in work with nonionising radiations. 4. Commencing Work with Non-ionising Radiations 4.1 Prior notification to the Laser Protection Adviser (LPA) The Head of Department shall notify the LPA of an intention to commence new work or to make changes to an existing work practice with non-ionising radiation in sufficient time for the work to be reviewed by the LPA and for the mandatory requirements below to be executed. 4.2 Prior risk assessment The LPA shall prepare a specific prior risk assessment. This shall be used to classify sources of non-ionising radiation as low risk, medium risk and high risk. Risk assessments for high risk devices shall be reviewed annually at audit. Risk assessments for medium and low risk devices shall be reviewed every three years. 4.3 Designation of areas Based on the prior risk assessment, the LPA shall advise on the need to control areas where work with non-ionising radiation is undertaken. 4.4 Laser Protection Supervisor (LPS), local rules and contingency plans 4.4.1 Departments with controlled areas shall have local rules in place and one or more appointed Laser Protection Supervisors to ensure that the local rules are adhered to. Staff working with non-ionising radiation shall sign that they understand and will abide by the local rules. 4.4.2 The Head of Department shall ensure that contingency plans are in place for dealing with emergencies involving high risk non-ionising radiation. These plans shall be outlined in the department s local rules. Staff shall be aware of contingency plans and these shall be rehearsed at suitable intervals. 4.5 Prior authorisation and training 4.5.1 Staff shall not undertake work with non-ionising radiation unless they are suitably qualified and trained and have received prior written authorisation to do so by the Head of Department. 4.5.2 The Head of Department shall set out the requisite education and training requirements for the particular role, which shall include suitable training in non-ionisingradiation protection. 5. Staff Responsibilities 5.1 Any employee working with non-ionising radiation shall: 4
Not knowingly expose himself or any other person to non-ionising radiation to an extent greater than is reasonably necessary for the purposes of his work. Abide by the departmental local rules and work instructions. Make full and proper use of any personal protective equipment supplied by the employer. Report to the Trust, via the Head of Department and/or LPS, any defect in personal protective equipment. Ensure that personal protective equipment is correctly stored. Comply with any reasonable requirement for dose assessment. Notify the Trust, via the Head of Department and/or LPS, if he/she has reason to believe he/she has received an overexposure. Notify the Trust, via the Head of Department and/or LPS, of any radiation incident or accident involving staff, visitors or patients. 6. Use of Personnel Protective Equipment (PPE) 6.1 Duties of staff 6.1.1 Staff shall wear the PPE provided in accordance with the local rules and/or work instructions for the controlled area in which they are working. Staff shall not stand behind other members of staff in the controlled area without wearing PPE. 6.1.2 Refusal to wear personnel protective equipment when it is a requirement of the local rules is an offence contrary to Section 7 of the Health and Safety at Work etc Act and will be treated as a disciplinary offence by the Trust. 6.1.3 Proper storage of safety glasses and visors is important to maintain the optical transmission integrity. Glasses and visors should be kept in a safe location, where they will not be excessively scratched or damaged. Where protective cases for eye protection are provided, they should be used. 6.2 When to wear PPE Staff and observers who cannot remain outside the controlled area shall wear appropriate PPE in accordance with the Local Rules for the room/theatre. If PPE is not worn, then they shall be told to leave the room. 6.3 Labeling and checking PPE Where there are several different sources of non-ionising radiation within a department, each item of PPE should be labeled to clearly indicate the source with which it should be used. Members of the department who use non-ionising sources and PPE are responsible for checking for damage to PPE and notifying the LPS in the event of any damage being found. In high risk areas where audits and testing are carried out, PPE will be checked on an annual basis by a member of Radiation Protection. If any replacement PPE or new PPE is obtained the LPS is responsible for contacting the LPA to ensure that it is suitable. 7. Management of Radiation Equipment 7.1 All the following paragraphs are applicable to equipment intended for medical exposures. Other equipment that emits non-ionising radiation but which is notintended for medical exposure is subject toparagraphs 5.1 and 5.2. 5
7.2 Procurement of Equipment 7.2.1 If a department intends to purchase, hire or otherwise obtain equipment that emits non-ionising radiation, the Head of Department must be satisfied that it is suitable and appropriate for the purpose for which it will be used. The LPA shall be advised if there is an intention to replace any existing medium or high risk source of non-ionising radiation. 7.2.2 The Laser Protection Adviser (LPA) shall be consulted to provide advice on radiation protection matters such as room requirements and personal protective equipment for the equipment. 7.3 Maintenance 7.3.1 All radiation equipment shall be under a regular maintenance contract. 7.4 Routine Performance Testing and audit 7.4.1 Routine performance testing shall be carried out at an interval agreed by the Radiation Protection Service, and based on a prior risk assessment, to monitor the performance of the equipment. Audit will be carried out annually by the Radiation Protection Service, for all non-ionising radiation sources identified by a prior risk assessment as high risk. 8. Training 8.1 Training will be required for all employees required to work with or are involved in work with non-ionising radiations. 8.2 The Head of Department shall set out the requisite education and training requirements for staff to ensure they are competent and confident with procedures, legislation and equipment associated with non-ionising radiations.. 9. Monitoring & Auditing 9.1 All risk events that have resulted in patient harm or near misses, must be reported on a Datix risk event reporting form. The LPS will review all risk events. All incidents and any trend analysis will be reviewed at the Radiation Protection committee. 9.2 A quarterly audit of compliance will be undertaken by reviewing all risk events related to the operation of this guideline. 9.3 Any immediate training or educational issues relating to the lack of compliance with this guideline will be addressed on a one to one basis. 10. Communications and Implementation 10.1 The LPS will be responsible for issuing copies to relevant Heads of Departments to disseminate to relevant staff and ensure they fully understand the guidelines. 10.2 The approved procedure will be notified in the Trust s Staff Focus and made available on the Trust s intranet & website. 6
11. Equality & Diversity 11.1 The Trust is committed to the provision of a service that is fair, accessible and meets the needs of all individuals. 12. References The Health and Safety at Work Act, 1974 (HASAW). Radiation Safety Management Ionising Radiations and non ionising Radiation, Radioactive Substances and Medial Radiation Exposures Policy number 13005 Trust Procedures for Medical Laser and Intense Light Source Safety Control of Artificial Optical Radiation at Work Regulations 2010 7