IAEA Training Material on Radiation Protection in Nuclear

IAEA Training Material on Radiation Protection in Nuclear Medicine Part 11 Potential Exposure Accidental Medical Exposure

OBJECTIVE To be able to identify hazardous situations which can result in accidental exposure and to take the necessary corrective actions. Case studies on accidental exposures and lessons learned. Nuclear Medicine Part 11. Potential exposure 2

Content Potential exposure, safety assessment Accident prevention, lessons learned Nuclear Medicine Part 11. Potential exposure 3

IAEA Training Material on Radiation Protection in Nuclear Medicine Part 11. Potential Exposure Accidental Medical Exposure Module 11.1. Potential exposure Safety assessment

Potential exposure Exposures that may or may not be delivered and to which a probability of occurrence can be assigned. (BSS) Nuclear Medicine Part 11. Potential exposure 5

SAFETY ASSESSMENT The licensee shall conduct a safety assessment applied to all stages of the design and operation of the nuclear medicine facility, and present the report to the Regulatory Authority if required. The safety assessment shall include, as appropriate, a systematic critical review of identification of possible events leading to accidental exposure (BSS IV.3–7). Nuclear Medicine Part 11. Potential exposure 6

SAFETY ASSESSMENT A review of the aspects of design and operation of a source which are relevant to the protection of persons or the safety of the source, including the analysis of the provisions for safety and protection established in the design and operation of the source and the analysis of risks associated with normal conditions and accident situations . Nuclear Medicine Part 11. Potential exposure 7

SAFETY ASSESSMENT Patient Request and scheduling Identification Information Administration of radiopharmaceutical Waiting Examination Leaving the department Nuclear Medicine Part 11. Potential exposure 8

SAFETY ASSESSMENT Source/worker Ordering Transport Receipt and unpacking Storage Preparation and administration of radiopharmaceutical Radioactive waste Nuclear Medicine Part 11. Potential exposure 9

SAFETY ASSESSMENT General public Transport Storage Handling of sources Radioactive waste Radioactive patient Nuclear Medicine Part 11. Potential exposure 10

SAFETY ASSESSMENT What can happen? Patient Procedure Incident Request and scheduling Identification Information Administration of radiopharmaceutical Waiting Examination Wrong patient Wrong patient Pregnancy, nursing Misadministration Contamination Contamination Bad quality Medical emergency Death of Leaving the department Nuclear Medicine patient Part 11. Potential exposure 11

SAFETY ASSESSMENT What can happen? Source/worker Procedure Incident Ordering Transport Unauthorized Transport accidents Loss of shipment Receipt and unpacking Storage Preparation and administration of radiopharmaceutical Radioactive waste Nuclear Medicine Part 11. Potential exposure Damage to package Loss of sources High dose to worker Contamination Loss of sources 12

SAFETY ASSESSMENT What can happen? General public Procedure Incident Transport Storage Handling of sources Radioactive waste Transport accident Loss of sources Spread of contamination Loss of sources Contamination Uncontrolled exposure and contamination Radioactive patient Nuclear Medicine Part 11. Potential exposure 13

EMERGENCY PLANS On the basis of events identified by the safety assessment, the licensee shall prepare emergency procedures (BSS V.2–6). The procedures should be clear, concise and unambiguous and shall be posted visibly in places where their need is anticipated. An emergency plan shall, as a minimum, list/describe: predictable incidents and accidents and measures to deal with them; the persons responsible for taking actions, with full contact details; the responsibilities of individual personnel in emergency procedures (nuclear medicine physicians, medical physicists, nuclear medicine technologists, etc.); equipment and tools necessary to carry out the emergency procedures; training and periodic rehearsal; recording and reporting system; immediate measures to avoid unnecessary radiation doses to patients, staff and public; measures to prevent access of persons to the affected area; and measures to prevent spread of contamination. Nuclear Medicine Part 11. Potential exposure 14

Loss of shipment Check all possibilities in the hospital. If still not found, call the company and inform them of the failure so they can trace the shipment and find out where the radioactive material is. If not found the loss of the material should be reported according to rules given by the Regulatory Authority Nuclear Medicine Part 11. Potential exposure 15

DAMAGE TO Tc-GENERATOR Evacuate the area immediately. Inform the RPO, who should confirm the spillage and supervise the decontamination and monitoring procedures. The event should be recorded and reported according to the rules given by the Regulatory Authority Nuclear Medicine Part 11. Potential exposure 16

Small amounts of radioactive spills Use protective clothing and disposable gloves Quickly blot the spill with an absorbent pad to keep it from spreading. A plastic bag to hold contaminated items shall be available as well as some damp paper towels Remove the pad from the spill Wipe with a towel from the edge of the contaminated area toward the centre Dry the area and perform a wipe test Continue the cycle of cleaning and wipe testing until the wipe sample indicates that the spill is cleaned The procedures should be practiced! Nuclear Medicine Part 11. Potential exposure 17

LARGE AMOUNTS OF RADIOACTIVE SPILLS The RPO should immediately be informed and directly supervise the clean-up. Absorbent pads may be thrown over the spill to prevent further spread of contamination. All people not involved in the spill should leave the area immediately. All people involved in the spill should be monitored for contamination when leaving the room. If clothing is contaminated it should be removed and placed in a plastic bag labeled ’RADIOACTIVE’. If contamination of skin occurs, the area should immediately be washed. If contamination of eye occurs, flush with large quantities of water. The procedures should be practiced! Nuclear Medicine Part 11. Potential exposure 18

EMERGENCY KIT Should be kept readily available for use in an emergency. It may include the following: protective clothing e.g. overshoes, gloves decontamination materials for the affected areas including absorbent materials for wiping up spills, decontamination materials for persons warning notices, portable monitoring equipment bags for waste, tape, labels, pencils. Nuclear Medicine Part 11. Potential exposure 19

FIRE The normal hospital drill should be observed and the safe evacuation of patients, visitors and staff is the most important consideration. When the fire brigade attend, they should be informed of the presence of radioactive material No one is allowed to re-enter the building until it has been checked for contamination. Nuclear Medicine Part 11. Potential exposure 20

MEDICAL EMERGENCY Contact the RPO for specific instructions. Medical personnel should proceed with emergency care while attempting to take precautions against spread of contamination: avoid direct contact with patient’s mouth, all members of the emergency team should wear impermeable protective gloves. Medical personnel shall be informed and trained in how to deal with a radioactive patient Nuclear Medicine Part 11. Potential exposure 21

MEDICAL EMERGENY Radiation protection considerations should not prevent or delay life-saving operations in the event surgery on the patient is required. The following precautions should be observed: Notify Notifythe theoperating operatingroom roomstaff. staff. Modify operating procedures Modify operating proceduresunder underthe thesupervision supervision of RPO to minimize exposure and spread of RPO to minimize exposure and spreadof ofcontamination. contamination. Protective Protectiveequipment equipmentmay maybe beused usedas aslong longas asefficiency efficiency and andspeed speedisisnot notaffected. affected. Rotation of personnel Rotation of personnelmay maybe benecessary necessaryififthe thesurgical surgical procedure is lengthy. The RPO should monitor individual procedure is lengthy. The RPO should monitor individual doses dosesto tomembers membersof ofthe thestaff. staff. Nuclear Medicine Part 11. Potential exposure 22

EMERGENCIES All people in the nuclear medicine department shall be trained in handling emergencies. Nuclear Medicine Part 11. Potential exposure 23

IAEA Training Material on Radiation Protection in Nuclear Medicine Part 11. Potential Exposure Accidental Medical Exposure Module 11.2. Accident prevention Lessons learned

Prevention of accidents and mitigation of their consequences The licensee shall incorporate within the RPP (BSS IV.10–12): defence in depth measures to cope with identified events, and an evaluation of the reliability of the safety systems (including administrative and operational procedures, and equipment and facility design); and operational experience and lessons learned from accidents and errors. This information should be incorporated into the training, maintenance and QA programmes; The licensee shall promptly inform the Regulatory Authority of all reportable events, and make suitable arrangements to limit the consequences of any accident or incident that does occur. Nuclear Medicine Part 11. Potential exposure 25

Accident Any unintended event, including operating errors, equipment failures and other mishaps, whose consequences or potential consequences cannot be ignored from radiation and safety point of view and which can lead to potential exposure and subsequently to abnormal exposure conditions. (BSS) Nuclear Medicine Part 11. Potential exposure 26

ACCIDENT EXAMPLE A 87 y old patient was administered a therapy dose of I-131 (7.4 GBq) in the hope of relieving esophageal compression caused by metastatic thyroid carcinoma. About 34h after receiving the dose the patient had a cardiopulmonary arrest and expired. Attempts at resuscitation were made in the patient’s room by 16 staff members. The efforts included insertion of a pacemaker. Contaminated blood and urine were spilled and no surveys of the clothing of those present were done. The highest personnel monitoring reading was 0.3 mGy for one of nurses. Even though the contamination was extensive, subsequent thyroid uptake measurements showed no uptakes by involved staff. Initiating event: Heart failure of patient shortly after iodine therapy Contributing factor: Contingency procedures for emergency situations involving radionuclides were not available. Monitoring instruments and decontamination equipment were not available. No simulation exercises had been performed. Nuclear Medicine Part 11. Potential exposure 27

Lessons learned from accidental exposure AAsafety safetyculture cultureshould shouldinclude includecollection collectionof ofinformation information on onunusual unusualevents eventswhich whichled ledor ormight mighthave haveled ledto to incidents incidentsand andaccidents. accidents.This Thisinformation informationprovides provides material materialthat thatcan canbe beused usedto toprevent preventfuture futureaccidents. accidents. Nuclear Medicine Part 11. Potential exposure 28

Safety culture The Theassembly assemblyof ofcharacteristics characteristicsand andattitudes attitudesinin organizations organizationsand andindividuals individualswhich whichestablishes establishesthat, that,as as an anoverriding overridingpriority, priority,protection protectionand andsafety safetyissues issues receive receivethe theattention attentionwarranted warrantedby bytheir theirsignificance. significance. (BSS) Nuclear Medicine Part 11. Potential exposure 29

Accidental Medical Exposure BSS II.29. Registrants and licensees shall promptly investigate any of the following incidents: (a) any therapeutic treatment delivered to either the wrong patient or the wrong tissue, or using the wrong pharmaceutical, or with a dose or dose fractionation differing substantially from the values prescribed by the medical practitioner or which may lead to undue acute secondary effects; (b) any diagnostic exposure substantially greater than intended or resulting in doses repeatedly and substantially exceeding the established guidance levels; and . Nuclear Medicine Part 11. Potential exposure 30

Accidental Medical Exposure BSS II.30. Registrants and licensees shall, with respect to any investigation required under para. II.29: (a) calculate or estimate the doses received and their distribution within the patient; (b) indicate the corrective measures required to prevent recurrence of such an incident; (c) implement all the corrective measures that are under their own responsibility; (d) submit to the Regulatory Authority, as soon as possible after the investigation or as otherwise specified by the Regulatory Authority, a written report which states the cause of the incident and includes the information specified in (a) to (c), as relevant, and any other information required by the Regulatory Authority; and (e) inform the patient and his or her doctor about the incident. Nuclear Medicine Part 11. Potential exposure 31

MISADMINISTRATION wrong radiopharmaceutical wrong patient wrong route of administration wrong activity therapy 10% from prescribed activity diagnosis 50% from prescribed activity Nuclear Medicine Part 11. Potential exposure 32

MISADMINISTRATION IN NUCLEAR MEDICINE 90 80 70 Percent 60 50 40 30 20 10 0 wrong pharmaceutical Nuclear Medicine wrong patient Part 11. Potential exposure wrong activity 33

Misadministration consequences ** ** ** ** ** ** Nuclear Medicine Non Nonjustified justifiedexposure exposure Increased Increasedradiation radiationrisks risks Delayed Delayeddiagnosis diagnosis Increased Increasedcosts costs Increased Increasedworkload workload Reduced Reducedconfidence confidence Part 11. Potential exposure 34

MISADMINISTRATION (wrong patient) A therapy dose of 350 MBq of I-131 was given to the wrong patient (patient A instead of patient B). Patient A was to receive 500 MBq Tc-99m for a bone scan. This dose was administered and the patient was seated in the waiting room. Patient B who was scheduled for an I-131 hyperthyroidism treatment arrived, completed an interview and was seated in the waiting room. The technologist prepared the activity of I-131 and called patient B. However, patient A responded. The technologist explained the treatment, scheduled a follow-up appointment and administered the activity. The patient then questioned the technologist and it became evident that the wrong patient had been treated. Patient A was immediately informed of the error and his stomach was pumped, retrieving about 1/3 of the activity. The patient was given perchlorate and Lugol’s drops to release any I-131 trapped in the thyroid and to block further uptake. The misadministration resulted in an absorbed dose to the thyroid of patient A of about 8 Gy. Initiating event: A patient responded to another patient’s name being called Contributing factor: Hospital protocol for identification of patients was not followed Nuclear Medicine Part 11. Potential exposure 35

Misadministration (wrong activity) A patient was to be administered 259 MBq I-131. The radiopharmaceutical was in two 130 MBq capsules and was so indicated on the vial label. Previous doses at the hospital had been administered in the form of one 259 MBq capsule. When the vial was inverted one of the two capsules fell out and the technologist assumed this was the entire dose. Much later the other capsule was detected. The patient received only 50% of the prescribed activity. Initiating event: One of two capsules remained stuck in the vial Contributing factor: Absence of cross check of the vial label with respect to both activity and number of capsules. No measurement of the activity before treatment. Nuclear Medicine Part 11. Potential exposure 36

Activity meter Correct settings? Nuclear Medicine Part 11. Potential exposure 37

Activity meter Setting Tc-99m Co-57 In-111 Tl-201 Ga-67 I-123 I-131 Nuclear Medicine Relative activity 1.00 1.19 2.35 1.76 1.12 2.19 1.43 Part 11. Potential exposure 38

Misadministration (wrong radiopharmaceutical) A technologist injected a patient with what he believed to be a radiopharmaceutical used for bone scan. Several hours later the patient was scanned. There was no evidence of bone uptake. Instead the patient appeared to have been injected with a radiopharmaceutical used for brain and kidney imaging. Initiating event: Wrong radiopharmaceutical Contributing factor: Improper labeling of the radiopharmaceutical (syringe) Nuclear Medicine Part 11. Potential exposure 39

Misadministration (wrong route of administration) A technologist scanned the nuclear medicine request form for a patient and noted that it involved Tc99mDTPA. The technologist draw a standard activity of the radiopharmaceutical and injected it before noting that the requested study required inhalation of the radiopharmaceutical in aerosol form. Initiating event: Wrong route of administration Contributing factor: No careful reading of the request form Nuclear Medicine Part 11. Potential exposure 40

Absorbed dose at injection site Radionuclide keV/disintegration Tc-99m 12.7 In-111 31.8 I-131 180.8 Sr-89 1463 Y -90 2283 Nuclear Medicine Part 11. Potential exposure 41

Misadministration (pregnant women) A 43y female patient was scheduled for a thyroid scan. She called the department in the morning and told the technologist that she was trying to get pregnant but there was no evidence at the moment that she was. The technologist misunderstood the patient and she was persuaded to make the examination. Later it appeared that the patient was pregnant at a very early stage and she had a miscarriage Initiating event: Examination of a pregnant woman. Contributing factor: Communication failure. Not working local rules. Nuclear Medicine Part 11. Potential exposure 42

PREGNANCY (BSS) Registrants and licensees shall ensure for nuclear medicine that: Administration of radionuclides for diagnostic or radiotherapeutic procedures to women pregnant or likely to be pregnant be avoided unless there are strong clinical indications. Nuclear Medicine Part 11. Potential exposure 43

IF YOU THINK THAT YOU MIGHT BE PREGNANT, NOTIFY STAFF BEFORE TREATMENT Nuclear Medicine Part 11. Potential exposure 44

MISADMINISTRATION A nursing mother was given 180 MBq of I-131 that resulted in absorbed doses to her infant estimated as 300 Gy to the thyroid and 0.17 Gy to the whole body. The error was detected when the patient returned to the hospital for a whole body scan. The scan indicated an unusual high breast uptake of I131. The infant will require artificial thyroid hormone medication for life to ensure normal growth and development Initiating event: A dose of I-131 was given to a nursing mother Contributing factor: The technologist was distracted and forgot to ask a standard list of questions Nuclear Medicine Part 11. Potential exposure 45

BREASTFEEDING (BSS) Registrants and licensees shall ensure for nuclear medicine that: For mothers in lactation, discontinuation of nursing be recommended until the radiopharmaceutical is no longer secreted in an amount estimated to give an unacceptable effective dose to the nursling Nuclear Medicine Part 11. Potential exposure 46

IF YOU ARE BREASTFEEDING, PLEASE NOTIFY THE STAFF Nuclear Medicine Part 11. Potential exposure 47

MISADMINISTRATION COUNTER MEASURES Immediately use all available means to minimise any adverse effects. Expedious removal of orally administered radiopharmaceuticals by emesis, gastric lavage, laxatives or enemas. Accelerated excretion of intravenously administered radiopharmaceuticals by hydration, diuresis etc. Removal of urine by catheterization from patients who cannot void spontaneously. When appropriate, use of blocking agents to diminish the absorbed dose to the thyroid gland, salivary glands and stomach. Nuclear Medicine Part 11. Potential exposure 48

If the conceptus is more than 8 weeks post conception (and the fetal thyroid may accumulate iodine) and the pregnancy is discovered within 12 hours of iodine administration, giving the mother 60 130 mg of stable potassium iodide (KI) will partially block the fetal thyroid and reduce thyroid dose. After 12 hours post radioiodine administration, this intervention is not very effective. Nuclear Medicine Part 11. Potential exposure 49

MISADMINISTRATION (causes) Communication problems Busy environment, distraction Unknown local rules No training in emergency situations Not clearly defined responsibilities No efficient quality assurance Nuclear Medicine Part 11. Potential exposure 50

How to avoid accidents and misadministrations Safety culture Safety assessment to define critical procedures and emergency situations Reporting system (When? Where? Why?) Education and training: initial, continuing Nuclear Medicine Part 11. Potential exposure 51

Investigation of accidental medical exposure Inform responsible nuclear medicine physician Inform patient and referring physician Calculate dose Indicate corrective measures Implement measures Submit report to RPC and Regulatory Authority Nuclear Medicine Part 11. Potential exposure 52

CONCLUSIONS Misadministration of radiopharmaceuticals should not be characterized as random human errors The Initiating event and the contributing factors can always be identified. This information provides material that should be used to prevent future accidents. Nuclear Medicine Part 11. Potential exposure 53

Questions? Nuclear Medicine Part 11. Potential exposure 54

DISCUSSION A shipment of 10 GBq I-131 was left unattended in the department. It disappeared. How to act! Nuclear Medicine Part 11. Potential exposure 55

DISCUSSION What type of accidents could happen in the room for preparation of radiopharmaceuticals? Nuclear Medicine Part 11. Potential exposure 56

DISCUSSION A patient containing 5 GBq I-131 has escaped from the isolation ward. How to act? Nuclear Medicine Part 11. Potential exposure 57

Where to Get More Information Other sessions Part 4 Safety of sources. Design of facilities Part 5. Occupational protection Part 6 Medical exposure Part 8 Radionuclide therapy Part 10 Radioactive waste Part 12 Protection of the public Further readings IAEA publications Nuclear Medicine Part 11. Potential exposure 58