A radiologist suffers radiation overexposure of the hands

On 20 October 2017, the Delafontaine Hospital Centre (Saint-Denis, France - 93 200) notified ASN of a significant radiation protection event affecting a radiologist performing fluoroscopy-guided interventional practices using a scanner. Due to late forwarding of the dosimeters to the laboratory responsible for analysing them, it was discovered in September 2017 that in the first quarter of 2017 this practitioner had received a dose on the hands exceeding the annual regulatory limit for a worker classified in category-A (dose to the "extremities" exceeding 500mSv).

The hospital centre took immediate measures after discovering the incident and the radiologist stopped all interventional procedures using the scanner. Analysis of the event shows that the majority of the dose was received by the radiologist when performing complex thoracic or abdomino-pelvic needle biopsies, during which his hands were exposed to the primary X-ray beam emitted by the scanner. Corrective measures have been put in place to optimise the protocols, improve the organisation of work on the interventional scanner, limit the exposure of the practitioner's hands during the procedures and ensure that the dosimeters are analysed within the required times.

ASN conducted an inspection concerning this incident on 24 January 2018. The efficacy of the first corrective measures was confirmed and a plan of action was developed in consultation with all the professionals concerned to prevent the occurrence of similar events. The inspection highlighted the need to:

• continue the optimisation of the examination protocols,
• change the practices of the medical practitioners concerned to avoid any exposure of the hands to the primary X-ray beam emitted by the scanner,
• improve the preparation of the patient prior to the procedure in order to facilitate the work of the radiologists.

The follow-up letter to this inspection can be consulted on www.asn.fr.

ASN firmly underlines the obligation for all workers who are exposed to ionising radiation to wear all their dosimeters, particularly in situations of heterogeneous exposure of the hands or the lens of the eye, in order to detect any abnormal exposure as early as possible. In view of the shortcomings observed in many hospitals concerning the wearing of extremity dosimeters in accordance with the regulatory provisions, ASN does not exclude the possibility that other similar cases of exposure might exist but go undetected.

Considering the exceeding of the annual exposure limit for the extremities, ASN rates this event level 2 on the INES scale (international scale of nuclear and radiological events, graded from 0 to 7 in increasing order of severity).