ASN Report 2017

285 ASN report on the state of nuclear safety and radiation protection in France in 2017 Chapter 09  - Medical uses of ionising radiation The main weak points in patient radiation protection highlighted yet again concerned the way the medical staff embrace the principles of exposure justification and optimisation. Thus, the precision of the justification factors on the examination request, the search for an alternative non- irradiating technique, and the training of medical professionals – particularly substitute physicians – in patient radiation protection, should be stepped up. The same finding was made for the optimisation of examination protocols and reviewing practices after analysing the diagnostic reference levels. 5.6.2 Significant events notified in computed tomography and radiology The very large majority of ESR notifications in computed tomography (165) in 2017 concerned patients (147). The most common case was the exposure of a pregnant woman who was unaware of her pregnancy (112 cases) or patient identity errors. The information provided to women before the procedure, when they made their appointment for the examination, and through the posters in the waiting rooms and undressing cubicles, was nevertheless satisfactory. About ten notifications concerned situations of accidental exposure of radiographers, essentially when tending to patients (18). In 2017, ASN was notified of 70 ESRs concerning the area of conventional radiology. The majority of the events (44 ESRs, i.e. 62%) concerned the exposure of pregnant women and identity monitoring errors. On the whole, ASN observes a decrease in vigilance in the search for potential pregnancies in women of childbearing age (e.g. performance of an abdominal ultrasonography examination after taking X-rays of the abdomen or the lumbar spine when these two examinations are requested). 5.6.3 Summary Although occupational radiation protection is satisfactory on the whole, in some cases the lack of means available to the RPE-Os still leads to shortcomings with regard to risk assessment, work environment analyses and continuous training. With regard to patient radiation protection in the area of computed tomography, the main lines for progress lie in the justification of examinations, optimisation of delivered doses and the analysis of the diagnostic reference levels. 5.7 Radiation protection situation in fluoroscopy-guided interventional practices For several years now, ESRs in the area of fluoroscopy-guided interventional practices have been regularly notified to ASN. Although these events represented just a small proportion (about 5%) of the medical events notified to ASN, they most often had serious implications with the occurrence of tissue damage (radiodermatitis, necrosis) in patients having undergone particularly long and complex interventional procedures. Added to these events which emphasise the major implications of radiation protection for patients, were the events concerning professionals whose exposure sometimes exceeded the regulatory limits, particularly at the extremities (fingers). On account of the radiation protection implications, ASN has increased the number of inspections it carries out in this sector in the last few years. In 2016, it conducted 155 inspections in 213 different departments which practice fluoroscopy- guided interventional procedures. In 2017, 178 departments were inspected. 5.7.1 Radiation protection of professionals using fluoroscopy- guided interventional procedures The findings established from the inspections carried out in 2016 confirm the observations made over the last few years. Thus, radiation protection of medical staff was still better applied in fixed interventional radiology facilities (cardiology, neuroradiology, vascular imaging, etc.) than in operating theatres in which mobile C-arm units are used (scanner, image intensifier, flat panel detector). The inspections on the whole still revealed inadequacies in the analyses of working environments and conditions, particularly with respect to doses to the extremities and to the lens of the eye, and in dosimetric monitoring (active and at the extremities). The lack of training of medical professionals, especially practitioners working in operating theatres, was a recurrent inspection finding in this sector in which a poor radiation protection culture was predominant. The training of operators using the fixed facilities however has progressed over time. Although collective radiation protection equipment was available for the dedicated activities, it was still too rarely present in operating theatres. Personal Protective Equipment (PPE) was available and worn by everybody, with the exception of lead glasses. The medical personnel in question showed little concern for their own radiation protection and were not aware of the doses they could and/or did receive, due in particular to the failure to wear the appropriate dosimeters (full body, extremities and lens of eye) even though they were available. The lack of appropriate dosimetric monitoring, particularly of the extremities in certain fluoroscopy-guided procedures, and the absence of medical monitoring of the practitioners, made it difficult to assess the status of worker radiation protection in this sector. ASN had nevertheless observed improvements in the inspected departments and greater awareness among professionals as a result of information feedback from the notified events. There were still methodological and organisational difficulties for the RPE-Os who did not always have the means or the necessary authority to perform their duties in full. Moreover, in the private sector, the analyses of private practitioners’ working practices and conditions, their dosimetric monitoring, their medical monitoring and, where applicable, that of their employees, represented a recurrent difficulty.