RADIATION SAFETY MANUAL For Columbia University NewYork-Presbyterian Hospital New York State Psychiatric Institute Barnard College September 2020 Radiation Safety Manual – September 2019 Table of Contents INTRODUCTION .................................................................................................................................. 3 Chapter I: Radiation Safety Program ...................................................................................................... 4 A. Program Structure and Jurisdiction .............................................................................................. 4 B. Roles and Responsibilities ......................................................... Error! Bookmark not defined. C. Radioactive Drug Research Committee ....................................................................................... 7 D. Radiation Safety Officers ............................................................................................................. 7 Chapter II: Radiation Safety Codes and Standards ................................................................................. 11 Chapter III: ALARA Program ............................................................................................................... 12 A. Management Commitment ......................................................................................................... 12 B. Training ...................................................................................................................................... 12 C. Monitoring of Individual Radiation Exposures.......................................................................... 12 D. Program Reviews ....................................................................................................................... 14 Chapter IV: Approval of the Use of Radiation ...................................................................................... 15 A. Research Applications................................................................................................................ 15 D. Clinical Applications ................................................................................................................. 18 Chapter V: Procurement of Radioisotopes and Other Sources of Ionizing Radiation ............................ 20 A. Research Applications................................................................................................................ 20 B. Clinical Applications ................................................................................................................. 20 C. Loans and Transfers of Radioactive Materials ........................................................................... 20 A. Occupational Exposure .............................................................................................................. 22 B. Monitoring of External Exposure .............................................................................................. 22 C. Monitoring of Internal Exposure ................................................................................................ 23 D. Summation of External and Internal Doses ............................................................................... 24 E. Reports and Notices to Workers ................................................................................................ 24 Chapter VII: Radiation Protection of the Pregnant Worker ................................................................... 26 Chapter VIII: Receipt of Packages Containing Radioactive Materials .................................................. 28 A. Packages Delivered to a Radiation Safety Program Office ....................................................... 28 B. Packages Received by Other Recipients .................................................................................... 28 Chapter IX: Safe Use of Radioactive Material and Radiation-Generating Equipment ........................... 29 A. Radioactive Materials ................................................................................................................ 29 B. Radiation-Generating Equipment .............................................................................................. 30 1. Types of Equipment: .............................................................................................................. 30 2. Purchase and Installation of Equipment ................................................................................. 30 Chapter X: Clinical Radiation Safety ..................................................................................................... 31 A. Safe Use of Radioactive Materials for Clinical Use .................................................................. 31 B. Safe Use of Sealed Sources ........................................................................................................ 32 C. Safe Use of Radiation-Generating Equipment ........................................................................... 32 D. Quality Assurance ...................................................................................................................... 32 E. Radiation Safety Compliance Audits ......................................................................................... 33 F. Radioactive Waste ..................................................................................................................... 33 G. Death or Surgery of a Patient Containing Radioactive Material ................................................ 33 1. Death ...................................................................................................................................... 33 2. Surgery ................................................................................................................................... 34 H. Medical Events ........................................................................................................................... 35 1. Reportable events ................................................................................................................... 35 2. Recordable events .................................................................................................................. 37 3. Contents of records ................................................................................................................ 37 4. Notification of referring physician and subject of medical event .......................................... 37 1 Chapter XI: Contamination and Radiation Surveys of Laboratories Using Radioactive Materials ....... 39 A. Surveys ....................................................................................................................................... 39 1. Fixed contamination surveys ..................................................................................................... 39 2. Wipe tests ................................................................................................................................... 39 3. Radiation field surveys............................................................................................................... 39 B. Action Levels ............................................................................................................................. 40 C. Record Retention ....................................................................................................................... 40 Chapter XII: Radioactive Waste Disposal ............................................................................................. 41 A. Waste Minimization ................................................................................................................... 41 B. No Drain Disposal ...................................................................................................................... 41 C. Radioactive Waste Guidelines ................................................................................................... 41 Chapter XIII: Security of Radioactive Materials ................................................................................... 45 A. General Statement ...................................................................................................................... 45 B. Radioactive Materials in Quantities of Concern ........................................................................ 45 Chapter XIV: Audit and Enforcement of Regulations, Policies and Procedures ................................... 47 A. Audits ......................................................................................................................................... 47 B. Violations ................................................................................................................................... 48 C. Deficiencies ................................................................................................................................ 48 Chapter XV: Inventory Control of Unsealed Sources ........................................................................... 50 Chapter XVI: Inventory and Leak Testing of Sealed Sources ............................................................... 51 Chapter XVII: Emergency Spill Procedures ......................................................................................... 52 A. Priorities ....................................................................................................................................