A practitioner’s regulatory annual exposure dose limit was exceeded


Print View Posted on: 12 February 2015

Event Date: 14 October 2014 Event Type: Other
Event Location: France, Bordeaux University Hospital - Pellegrin Hospital INES Rating: 2 (Final)

On 14th October 2014, ASN was informed by Bordeaux CHU that the regulatory annual whole-body dose limit of 20 mSv was exceeded by an orthopaedic surgeon while using an interventional radiology device (image intensifier) in the operating theatre.

The event came to light when the practitioner’s passive dose monitoring results were received and showed that the dose received between June 2013 and June 2014 was 25 mSv.

The investigations carried out by the hospital were unable to identify the causes of this exposure and more specifically whether the practitioner was regularly using individual protection equipment. Furthermore, the surgeon’s failure to wear an operational dosimeter meant that the measurement results could not be compared with the passive dosimetry results.

ASN carried out an inspection on 1st December 2014 on the unit in which the event had taken place. This was the subject of a letter requesting corrective measures, in particular concerning the actual wearing of dosimeters by all the professionals concerned and the deployment of collective protection equipment.

INES Rating: 2 - Incident (Final) as per 22 December 2014
Release beyond authorized limits? No
Overexposure of a member of the public? No
Overexposure of a worker? Yes

Contamination spread within the facility? No
Damage to radiological barriers (incl. fuel damage) within the facility? No

Degradation of Defence In-Depth No

Person injured physically or casualty? No
Is there a continuing problem? No

Erik Ducousso
Autorité de Sûreté Nucléaire (ASN)

erik.ducousso@asn.fr
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