The regulatory climate surrounding the use of radioactive materials has become increasingly harsh and unforgiving. Severe penalties and fines have been imposed recently on hospitals that have failed to use their authorized materials safely or not in compliance with their license. This policy is designed to encourage the participation and cooperation of the users of radioactive materials to ensure their safe use of radioactive materials consistent with the rules and regulations of the Department of Natural Resources of the State of Georgia.
2.1 The responsibility for safe use of radioactive materials is placed on the authorized users as well as the Radiation Safety Office and the Radiation Safety Committee (RSC). A system of consequences for violations of regulations concerning the safe use of radioactive material will be used for educating and alerting the authorized users, motivating individual users, and determining future user authorization for use of radioactive materials.
2.2 A violation will generally be identified by a member of the Radiation Safety Office during a monthly laboratory survey. This does not preclude violations being identified at other times or being identified through self-reporting by the user. When identified, class C enforcement actions may be taken by the Radiation Safety Officer (RSO) without consulting the RSC. The enforcement actions for classes B and A violations will be taken by either the RSO or the RSC as specified below. Matters of mitigation or extenuation relative to a violation will be considered by the person or committee having enforcement action authority. The RSC will be the final arbiter on all unresolved disputed violations (see Appeal Process below). The RSO retains his current responsibility to suspend any operation that threatens the health and safety of the patients, staff, or public.
3.0 Appeal Process
3.1 Users will have the opportunity to appeal a decision made by either the RSO or RSC. The appeal will be a formal, typed response from the user to the RSO who will, in consultation with the appropriate RSC members, consider the appeal.
3.2 The appeal letter must be received by the RSO within 5 working days of receipt by the user of the written notice of violation. The appeal will be acted on and the user notified of the results within 5 working days of the receipt of the appeal letter by the RSO.
4.1 Violations have been divided into three categories ( A, B, and C ), with category A being the most serious. Spills and accidents are not violations unless they have been caused by failure to comply with regulations and/or conditions of a user’s authorization to use radioactive materials.
4.2 Class C violations are the least serious and include, but are not limited to the following:
4.2.1 Failure to maintain proper radioactive materials inventory
4.2.2 Failure to perform or record weekly contamination surveys
4.2.3 Failure to report a significant spill (millicurie range) or incident to the Radiation Safety Office
4.2.4 Failure to use proper procedures when opening newly acquired radioactive material
4.2.5 Failure to properly label radioactive materials
4.2.6 Failure to properly package radioactive materials for shipping or disposal
4.2.7 Failure to follow no eating, drinking, or smoking policy in a radioactive material laboratory
4.2.8 Failure to wear dosimetry at appropriate times
4.2.9 Failure to notify Radiation Safety Office of arrival of new personnel who require training and/or dosimetry
4.2.10 Failure to wear appropriate protective clothing in the laboratory
4.2.11 Failure to be bioassayed when required
4.2.12 Failure to properly identify radioactive waste to include isotope, activity, and composition
4.3 Class C violations will result in:
4.3.1 Verbal and written notification of the violation by the RSO or his representative
4.3.2 Upgrade to class B violation if not corrected within 14 days, or if a similar violation is repeated within 90 days
4.4 Class B violations are usually a result of repeat of class C violations. They include but are not limited to the following:
4.4.1 Failure to comply with written notices from the RSO
4.4.2 Failure to notify the Radiation Safety Office prior to change of location or disposal of contaminated (or potentially contaminated) equipment
4.4.3 Failure to require proper training or dosimetry for personnel working with radioactive materials
4.4.4 Failure to properly store and/or secure radioactive material
4.4.5 Failure to segregate radioactive material from hazardous materials such as benzene, toluene, ether, or chloroform
4.5 Class B violations will result in:
4.5.1 Immediate verbal notice of the violation by the RSO or his representative
4.5.2 Written notice of the violation with copies sent to the RSC Chairman and appropriate members of the RSC
4.5.3 Possible suspension of the privileges of ordering radioactive material, by the RSC until the violation is corrected
4.5.4 Upgrade to class A violation if not corrected within 14 days, or if a similar violation is repeated within 180 days
4.6 Class A violations are usually a result of repeat of class B violations. They also include but are not limited to the following:
4.6.1 Falsification of required radiation safety records
4.6.2 Failure to comply with written notices from the RSC
4.6.3 Failure to report loss or theft of radioactive material
4.6.4 Unauthorized shipment or receipt of radioactive material
4.6.5 Pipetting of radioactive material by mouth
4.7 Class A violations will result in:
4.7.1 Immediate verbal notification of the violation by the RSO or his representative
4.7.2 Written notice of the violation by the RSO or his representative with copies sent to the RSC Chairman and the appropriate member(s) of the Committee
4.7.3 Possible suspension of radionuclide ordering privileges by the RSO
4.7.4 Possible suspension of authorization to use radionuclides, at the discretion of the RSO, pending review by the RSC
4.7.5 Possible termination of authorization based on a majority vote of the RSC.