Lens of the eye overexposure to interventionalist radiologist

Print View Posted on: 26 June 2020

Event Date: 31 December 2019 Event Type: Other
Event Location: United Kingdom, United Kingdom, Wales, Hospital INES Rating: 2 (Final)

During interventional radiography procedures for medical purposes, one operator received a cumulative dose to the lens of the eye, over one year, in excess of a statutory dose limit. The increasing dose to the lens of the eye was not observed in the monthly dosimetry reports until the end of 2019. Several failures were identified including failure of management systems, irregular use of personal protective equipment (PPE) and use of dosimetry not approved to measure the equivalent dose to the lens of the eye.
Dose estimates have been made based using assumptions that were judged as realistic based on operator recollection of PPE use. The operator has not reported any deterministic effects to the eye.
Based on the available information the best estimated equivalent doses to the lens of the eye were 25.8 mSv
The annual dose limit in the UK for the lens of the eye is 20.0 mSv according to the relevant legislation.
The incident has been investigated by the Health and Safety Executive of Great Britain and the case is now closed following a decision not to prosecute.

INES Rating: 2 - Incident (Final) as per 19 June 2020
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

Ivaylo Evgueniev Stanev
Office for Nuclear Regulation (ONR)

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