Title:

University of Texas Southwestern Medical Center At Dallas Radiation Safety

GENERAL PROVISION OPERATING AND SAFETY PROCEDURES

Procedure No. 20 Date: February 14, 2001 Revised: August 2, 2005 Page 1 of 5

NOTE: Although allowed by regulation, by policy IFS staff may not hold a body while xrays are taken; IFS staff must operate x-ray machines from behind the lead lined operator wall where feasible. I. Purpose
Operating and safety procedures are required by 25TAC289.227(i)(2) and 25TAC289.229(h)(1)(D). The procedures are provided to comply with rules enforced by the Department of State Health Services (DSHS), Regulatory Services Branch. The certificate of registration contains conditions and restrictions that apply to the operation of the radiation machines and simulators in this facility. These regulations are available at the University of Texas Southwestern Medical Center, Radiation Safety Office, S1.1ZZ, for your review. Each sub-site also has available copies of the pertinent rules and required documentation.

II. Scope
OPERATING AND SAFETY PROCEDURES FOR: UT Southwestern Medical Center and Sub-sites 5323 Harry Hines Blvd., MC-9053 Dallas, TX 75390 Telephone: (214) 648-2250 The Radiation Safety Officer (RSO) has the responsibility and authority for assuring safe radiation practices and serves as the contact person between this facility and the DSHS for the registration of all radiation machines. Direct all your questions or concerns on radiation safety to the RSO. A. Credentials Section not applicable to morgue facilities. B. Operator and Patient Safety 1. Use of Protective Devices for Radiographic/Fluoroscopic Equipment and Simulators
a.

Section not applicable to morgue facilities.

(i) Section not applicable to morgue facilities (ii) Section not applicable to morgue facilities (iii) Section not applicable to morgue facilities (iv) Section not applicable to morgue facilities (v) The operator position during exposure shall be such that the operators exposure is ALARA (as low as reasonably allowable) and the operator is positioned six feet from the source of radiation or using protective devices. b. Section not applicable to morgue facilities. c. Section not applicable to morgue facilities 2. Holding of patients and/or film

Title:
University of Texas Southwestern Medical Center At Dallas Radiation Safety
GENERAL PROVISION OPERATING AND SAFETY PROCEDURES

Procedure No. 20 Date: February 14, 2001 Revised: August 2, 2005 Page 2 of 5

a. Radiographic procedures: If a patient or film must be supported during a radiation procedure, use a mechanical holding device when circumstances permit. If it becomes necessary for an individual to hold a patient or film, the holder should not be pregnant and must be older than 18 years of age. They must wear protective devices and keep out of the direct beam. Other technologists and volunteer service workers should not be used to assist in the holding of patients and/or film. b. When the patient must hold the film then any portion of the body not in the area of clinical interest shall be protected by >0.25 mm lead equivalent material. c. Section not applicable to morgue facilities. 2. Exposure of Personnel a. No individual shall be in the x-ray room while exposures are being made unless such individuals assistance is required and that individual is protected with appropriate shielding devices. b. Gonadal shielding shall be used on patients when the gonads are in or within 5 cm of the useful beam. This requirement does not apply if the shielding will interfere with the diagnostic procedure. Gonadal shielding shall be of at least 0.5 mm lead equivalent material. c. For therapeutic radiation systems operating at or below 150 kVp, no individual other than the patient shall be in the treatment room unless the individual is protected by a barrier sufficient to meet the requirements of 25 TAC289.231(o). d. For therapeutic radiation systems operating above 150 kVp, no individuals other than the patient shall be in the treatment room during exposures. 4. Patient protection Section not applicable to morgue facilities. 5. Notices, Instructions, and Reports to Workers The following items must be posted in a conspicuous area or a document must be posted that states where the following items may be examined. a. b. c. d. DSHS Form "Notice to Employees" Certificate of Registration Operating and safety procedures Notices of violations involving radiological working conditions issued by DSHS.

All individuals likely to receive in a year an occupational dose in excess of 100 mrem shall receive instruction in accordance with 25 TAC289.203(c). Instruction shall be commensurate with the potential radiological health protection problems associated with the source(s) of radiation in the workplace. Radiation exposure data for an individual and the results of any measurements, analyses, and calculations of radioactive material deposited or retained in the body of an individual shall be reported to that individual as specified in 25 TAC289.203(d). A written report shall be provided to the individual for any reports made to the agency of any exposure of that worker to sources of

Title:
University of Texas Southwestern Medical Center At Dallas Radiation Safety radiation. 6. Posting of Radiation Areas
GENERAL PROVISION OPERATING AND SAFETY PROCEDURES

Procedure No. 20 Date: February 14, 2001 Revised: August 2, 2005 Page 3 of 5

Each radiation area shall be posted with a conspicuous sign or signs in accordance with 25 TAC 289.231(x) and (y). Radiation areas are exempt from the posting requirements provided that the operator has continuous surveillance and access control of the radiation area.

C. Occupational Dose Limits Operations of each facility shall be conducted so that occupational dose limits and dose limits for individual members of the public are in accordance with 25 TAC289.231(m) and (o). Any adult who is likely to receive a dose from occupational exposure to radiation in excess of 500 millirem in a year must use an individual monitoring device. Declared pregnant women who are likely to receive a dose from occupational exposure to radiation in excess of 50 millirem during the entire pregnancy must also use an individual monitoring device. The use of any individual monitoring device shall be in accordance with the UT Southwestern Medical Center Procedure 3 for Personnel Monitoring, and in accordance with 25 TAC289.231(n). UT Southwestern Medical Center is responsible for the occupational dose records and exchange of the individual monitoring devices. The individual monitoring device readings (badge reports) are located at UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX. Copies of these reports are posted at each sub-site for review. If you are working for another employer and receive an occupational dose, you should report that dose to the RSO so that it may be included in your annual record of occupational dose. 1. Pregnant Employees If any employee is pregnant or becomes pregnant, she may voluntarily inform the RSO in writing of the pregnancy. If the RSO is informed of the pregnancy, the facility will monitor the radiation dose to the embryo/fetus with a waist badge. A declared pregnant worker may not receive an exposure to radiation in excess of 0.5 rem (500 mrem) during the entire pregnancy. 2. Radiation Incident or Overexposure If you suspect there has been an excessive exposure or a radiation incident, immediately notify the RSO. D. Operation of Radiation Machines 1. Diagnostic X-ray Exams Not applicable to morgue facilities 2. Therapeutic X-ray Exams

Title:
University of Texas Southwestern Medical Center At Dallas Radiation Safety Not applicable to morgue facilities 3. Morgue facilities
GENERAL PROVISION OPERATING AND SAFETY PROCEDURES

Procedure No. 20 Date: February 14, 2001 Revised: August 2, 2005 Page 4 of 5

Morgue facilities shall comply with the following: Section B.1.a (v), B.2.a and b., B.3, B.5 and B.6, Section C and Section D.7, D.8, D.9 and D.11 and Section E. For hand-held devices Section D.11.c. 4. Equipment Performance Evaluations Not applicable to morgue facilities 5. Therapeutic Systems Calibration Not applicable to morgue facilities
6.

Therapeutic systems security Not applicable to morgue facilities

7. Operator Position During Exposure a. The operator must be able to continuously view and communicate with the patient. b. During the exposure, the operator must be positioned so that the operator exposure is as low as reasonably achievable (ALARA) and/or the operator is protected by a lead apron, gloves or other shielding. 8. Use of a Technique Chart A technique chart relevant to the particular radiation machine shall be provided or electronically displayed in the vicinity of the control panel and used by all operators. 9. Restriction and Alignment of the Beam The useful x-ray beam shall be restricted to the area of clinical interest. Use the centering and beam limiting devices (collimator) provided on the radiation machine. 10. Use of Fluoroscopic Machines Not applicable to morgue facilities

Title:
University of Texas Southwestern Medical Center At Dallas Radiation Safety 11.
GENERAL PROVISION OPERATING AND SAFETY PROCEDURES

Procedure No. 20 Date: February 14, 2001 Revised: August 2, 2005 Page 5 of 5

Use of Mobile or Portable Machines a. During the exposure the operator: (i) must be positioned so that his/her exposure is as low as reasonably achievable (ALARA) (e.g. 6 feet or more away); and/or (ii) must wear a lead apron, gloves if necessary, or be protected by other shielding; and (iii) should never be in line with the direct beam. b. The x-ray tube housing shall not be held by an individual during any radiographic exposure. c. Portable radiation machines designed to be hand-held are exempt from D.10.b. The portable radiation machine shall be held by the tube housing support or handle.

E. Film Processing 1. Film Processing a. Films shall be developed by the time and temperature recommended by the film manufacturer. The specified developer temperature for automatic processing and the time-temperature chart for manual processing shall be posted in the darkroom. b. Chemicals shall be replaced according to the chemical manufacturer or suppliers recommendations or at an interval not to exceed three months. c. Darkroom (film processing/loading area) light leak tests shall be performed at intervals not to exceed six months and any light leak correction initiated within 72 hours. A record of the test shall be kept for three years. The test shall include a check of the proper filter, safe light bulb wattage and distance from work surface. 2. Alternative Processing Systems Users of daylight processing systems, laser processors, self-processing (Polaroid) film units, or other alternative processing systems shall develop procedures following manufacturer's recommendations for image/film processing. 3. Digital imaging acquisition systems. Users of digital imaging acquisition systems shall comply with the manufacturers recommendations for quality assurance.