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You are here: Home rad manual THE RADIATION SAFETY PROGRAM


by schmidy last modified Nov 09, 2009 09:23 AM



Individuals working in or frequenting restricted areas in the university must be informed of radioactive material presence, storage, use, and radiation levels present. Nursing, housekeeping, security and other personnel frequenting areas where radioactive material is utilized or stored will be given radiation safety instructions at least annually.

Personnel who utilize radioactive material will be instructed on applicable provisions of applicable 902 KAR 100 regulations and license conditions, including incident reporting responsibilities, and the right to know their exposure/bioassay results; before commencing work, after significant program changes, and annually thereafter. A copy of, or the location of the regulations, radioactive material license, guides, laboratory rules, procedures, survey results and personnel monitoring records will be available to these individuals and they will be instructed in appropriate portions (Appendices H, I and J). Training records will be retained for review.

Radiation Workers will be trained on good radiation safety practices. Uniforms or lab coats are worn during duty hours and gloves donned when handling liquid radioactive material or potentially contaminated articles. Absorbent material will be laid down prior to mixing or preparing unsealed sources of radioactive material. Syringe and vial shields and handling devices (tongs, forceps, etc.) are available and are to be used to minimize extremity and whole body dose.

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Airborne Contamination


Individuals wishing to be authorized for gases (ie Xe-133) should contact the Radiation Safety Office. The RSO will evaluate each proposed use as per Appendix M of "A Guide for the Preparation of Radioactive Material License Applications for Medical Programs" (Areas where radioactive gases are utilized must have air flow measurements performed semi-annually). Aerosolized radionuclides are administered within a closed, shielded system that provides for collection and disposal of the aerosol. Trap filters are not reusable. They will be properly shielded and held for decay as per Appendix L.


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Personnel Monitoring

All personnel who directly handle gamma or high energy Beta emitting radioactive material shall be provided with, and wear, a whole body personnel monitoring device, such as a film badge or thermo luminescent dosimeter (TLD). These monitoring devices will be procured from a NLVAP certified dosimetry service and will be changed at least quarterly. Individuals who are occupationally exposed on an occasional basis (ie nurses caring for therapy patients) shall be issued a whole body monitor during the period of potential exposure. The monitoring device is to be worn in a manner such that the dose it receives can be expected to approximate the maximum radiation dose to the head and/or trunk of the wearer. Individuals wearing lead aprons should wear two film badges, one on the trunk of the body, under the apron and the other on the collar outside the apron.

Personnel who directly handle millicurie amounts of radioactive material shall also be provided with finger film or TLD badges. Other personnel will be assigned appropriate personnel monitoring devices as deemed appropriate by the RSO.

Individuals may only wear personnel monitoring devices which have been directly assigned to them. Personnel monitoring devices shall not be exchanged with other individuals. The RSO will assign temporary devices in the event of loss, accident or emergency. Any dose recorded by the temporary device will be incorporated into the assigned individual's permanent dose record. The personnel monitoring records, including the name, sex, social security number, date of birth and work station of each participant, will be kept on file in Nuclear Medicine and Radiation Oncology. A duplicate copy will be kept in Radiation Safety. The RSO will review these records quarterly to determine which individuals may be receiving significant exposures. Film badges should be ordered using the "Personnel Monitoring Badge Action Form", Appendix E .

Investigations of overexposures, serious accidents and spills of radioactive material should be impartially conducted by the RSO to permit correction of any conditions that could have lead to the event. Such investigations are important since they may discover defects in previously accepted procedures or equipment. Positive corrective action can then be taken immediately. A written report should be prepared so that others may benefit from the experience.

The various lead brick and other radiation shields in the Hot Lab are to be used to best advantage in reducing exposure rates from sources such as Mo-99/Tc-99m generators, and stored product inventory. Spent generators shall be stored in their lead shipping shields until disposal or returned to the vendor.

Restricted areas shall be under surveillance by personnel as a security measure. When unattended, stored radioactive material must be secured by lock and key. Key control is maintained through the RSO, Radiology Supervisors, Nuclear Medicine Technologists and security staff.

Radioactive material will be transported to patient areas only as absolutely necessary and then while properly posted, labeled and shielded.

Radiation safety surveys will be conducted as per Appendix K.

The State of Kentucky Radiation Control Branch will be notified whenever overexposures exceed regulatory limits:

  1. Whole body Total effective dose equivalent greater than 5.0 rem/year
  2. extremity dose greater than 50 rem/year.

Bioassay will be performed on every individual that either prepares or administers volatile radioactive material (i.e. >30 mCi of I-131 sodium iodine). Bioassay will be preformed within three (3) days, of administration or preparation, as per Appendix O.

The University of Louisville has instituted a policy regarding exposure to the fetus of the "Declared" pregnant worker. This policy has been approved by the Radiation Safety Committee and the Administration of the University of Louisville. Any occupationally exposed workers wishing to declare their pregnancy should follow the policy outlined in Appendix EE.


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Sealed Sources


All radioactive sources requiring periodic leak tests will be tested according to 902 KAR 100.060 regulations by University Radiation Safety Personnel, using the procedures in Appendix N. Sealed sources for medical use and dose calibrator sources above the exempt quantities listed 902KAR100:080 will be inventoried quarterly and records showing quantities and kinds of radioactive material, location of sources, date of inventory and survey of storage location, shall be maintained for review.


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Waste Disposal


  1. Solid Waste.

    Solid waste will be held for decay or disposed as de minimus as per 902 KAR 100:021 (Appendix L), or transferred to an NRC or Agreement State or NRC licensed disposal service. All material transferred to another licensee will be shipped in accordance with applicable state or U.S. DOT regulations. Records of such transfers will be kept.

  2. Liquids

    No liquid radioactive waste will be released via the sanitary sewerage system except human excreta from Nuclear Medicine procedures.


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Radiation safety procedures and instructions for the handling of patients containing therapeutic amounts of radioactive material


Hospital Routine

For patients requiring hospitalization, the RSO shall be notified in advance when a patient is to be given a therapeutic amount of radioactive material and informed of the radionuclide, planned dosage and when it is to be administered. The RSO will then make special radiation safety arrangements, including radiation measurements:

  1. At bedside
  2. One meter above the patient to establish presence of thirty millicuries or greater gamma emitting radiopharmaceutical
  3. The surrounding uncontrolled areas, placement of necessary caution signs on the bed or room
  4. Posting of Nursing Care instructions

See Appendices M, for more detailed instructions. Rubber or plastic gloves shall be available and worn whenever contamination is suspected. Surveys shall be conducted anytime contamination is suspected.


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Release or Discharge from the hospital of patients containing radioactive material.

Patients containing or receiving radioactive material shall remain hospitalized until the sources are removed or their content of radioactivity is reduced to an acceptable level (Appendix S). After release of the patient, an exit survey shall be performed to assure absence of radioactive contamination. For residual activities, established guidelines will be followed (Appendix T).


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Emergency Surgery or death of a patient containing radioactive material.

  1. Contact Radiation Safety (852-5231) if Emergency Survey is required. Scheduled surgery, as a planned follow-up to the administration of radionuclides should be delayed until after a 24 hour period.

  2. The surgeon or pathologist who may be called upon to work with the patient or body containing radioactive material should be fully informed that he is dealing with radioactive material and be monitored during the procedure.

  3. If a radioactive patient dies in the hospital, the physician who pronounced the patient dead shall contact the physician in charge of the case and the RSO shall be notified at once.

  4. Autopsies may be carried out only after consultation with the RSO.

  5. The funeral director will be notified and instructed in special precautions as deemed necessary by the RSO (See Appendix U).


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Radiation Emergencies

Relatively large quantities of radioactive material are available in a nuclear medicine department. Much of the total quantity is in a liquid form, normally contained by glass or plastic. Should a container be broken, all the avenues of exposure are then available -- direct exposure, surface contamination, airborne contamination, and ingestion. Radiation workers must be alert to prevent conditions, which might lead to an emergency situation, and to respond appropriately should an emergency arise.

The most probable radiation emergencies are considered to be:

  1. Radioactive Material Spills
  2. Spills present a hazard to personnel through direct exposure and contamination. The best protection is through effective preventive, containment, and cleanup efforts. Specific spill procedures have been developed (Appendix H) and are posted at appropriate locations. Thorough familiarity with these procedures is important to assure proper immediate response.

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  3. Fire
  4. Fire is an emergency in itself that may be compounded when radioactive material is involved. Heat may destroy glass and plastic containers of radioactive liquid or melt lead radiation shielding.

    Combustible materials should be kept to an absolute minimum in areas where radioactive materials are utilized or stored. Know the fire response procedures; how to turn in an alarm and how to contact the local fire department. Notify the fire department of the presence of radioactive materials and brief its staff on special precautions to be taken when entering a restricted area.

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  5. Decontamination
  6. Contamination precautions and decontamination procedures are maintained for the protection of the people administering radioactive substance. Rigid techniques help control contamination. It is an unwritten law for personnel working with radionuclides that they decontaminate their own "spills" and area, under the supervision of the Radiation Safety Officer.

    Procedure to Follow:

    1. Put on disposable gloves (also boots if necessary) before entering the room or area.
    2. Prevent liquid from spreading (contain by placing any absorbent material over the spilled liquid).
    3. Monitor the spill, equipment, or people involved to determine the amount of radiation being emitted.
    4. All persons not involved and not contaminated should remove themselves from the area immediately.
    5. Contaminated clothing, including shoes, should be removed before the individual leaves the area. Thorough washing should be accomplished immediately.
    6. Monitor personnel after washing. Repeat washing as necessary. Excessive scrubbing of the body should be avoided. Use of hot water should be avoided because it increases circulation to the contaminated area of the body and enhances the absorption of radioactivity into the circulating blood. Warm water and mild soap is recommended.
    7. Radioactive particles are more easily removed from hard surfaces, such as stainless steel basins, than from more porous materials.
    8. Minor cuts should be encouraged to bleed, thereby reducing absorption capabilities. The treatment of major cuts should be considered before contamination.
    9. Brushes are not good for applying friction to a surface. The bristles cause splattering and spreading of contamination.
    10. Place all trash and waste in moisture proof containers for removal from the area.
    11. Wash and monitor yourself thoroughly; this is essential. Contamination under the fingernails becomes the major problem in the decontamination of hands.
    12. Report the incident as required by procedures.


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