By Arif Subhan, MS, CCE, FACCECCE-Prep-Arif-Subhan

This article, covering the Radiation Safety Committee (RSC), is a continuation of the previous article on Committee Management that appeared in the January 2013 issue, which discussed the hospital Infection Control Committee. This article will review the hospital RSC’s responsibilities and roles.

The hospital RSC has the overall responsibility for managing and developing polices and guidelines for the safe use of all sources of radiation. It includes all clinical (and research) uses of radioactive materials and ionizing and nonionizing radiation generating devices. A clinical/biomedical engineering department should be an active member of the RSC.

Roles and Responsibilities

The RSC has many responsibilities, including approving the training of health care professionals (eg, physician, dentist, radiologic technologist) who use ionizing radiation sources for human use; reviewing and approving the use of radiation sources; developing and recommending corrective action for deficiencies with the radiation safety program; reviewing occupational radiation exposure records of staff; and developing corrective action for radiation incidents.1

The RSC needs to be aware of the various standards and regulations pertaining to radiation safety.

Depending on the location and type of the facility, the RSC needs to be aware of the various standards and regulations pertaining to radiation safety. The following lists organizations that have standards and regulations regarding the use of radiation devices.

The United States Nuclear Regulatory Commission

The US Congress created the United States Nuclear Regulatory Commission (NRC) in 1974 as an independent agency to ensure the safe use of radioactive materials for civilian use, while at the same time protecting people and the environment. Besides regulating commercial nuclear power plants, the NRC also regulates other uses of nuclear materials, such as in nuclear medicine, through licensing, inspection, and enforcement of its requirements. The governing legislation can be found on the NRC website.2

The NRC requires medical facilities to establish a Radiation Safety Committee. According to 10 CFR 35.24, “The Committee must include an authorized user of each type of use permitted by the license, the Radiation Safety Officer, a representative of the nursing service, and a representative of management who is neither an authorized user nor a Radiation Safety Officer.” An authorized user would be those who use radioactive materials, such as in nuclear medicine or diagnostic radiology, radiation oncology, cardiology, and clinical research.3

Joint Commission Standards

The Joint Commission standard EC.02.02.01 EP7 states that, “The hospital minimizes risks associated with selecting and using hazardous energy sources. Note: Hazardous energy is produced by both ionizing equipment (for example, radiation and x-ray equipment) and nonionizing equipment (for example, lasers and MRIs).”4

The FDA

The Center for Devices and Radiological Health (CDRH) under the FDA is responsible for protecting and promoting the public health. The CDRH “assures that patients and providers have timely and continued access to safe, effective, and high-quality medical devices and safe radiation-emitting products.”5 The laws and regulations pertaining to radiation were originally enacted as the Radiation Control for Health and Safety Act of 1968 and are located in Sections 531 through 542 of the Act.

National Council on Radiation Protection and Measurements

The US Congress chartered the National Council on Radiation Protection and Measurements (NCRP) in 1964. Its objectives include developing and disseminating information and recommendations about protection against radiation and radiation measurement units. NCRP produces many scientific reports. One of the NCRP reports—“No. 147, Structural Shielding Design for Medical X-Ray Imaging Facilities”—has recommendations and technical information related to the design and installation of structural shielding for facilities that use x-rays for medical imaging.

Various states have specific requirements regarding radiation protection, designed to protect the public, radiation workers, and the environment.

Various governmental organizations like the NRC and state governments utilize NCRP’s recommendations as the scientific foundation of their radiation-protection actions. NCRP also works with different international bodies concerned with radiation protection, such as the International Commission on Radiological Protection (ICRP).6

State Regulations

Various states have specific requirements regarding radiation protection. For example, the California Radiologic Health Branch enforces the state laws and regulations that are designed to protect the public, radiation workers, and the environment. The Radiologic Health Branch is responsible for the “licensing of radioactive materials, registration of x-ray-producing machines, certification of medical and industrial x-ray and radioactive material users, inspection of facilities using radiation, investigation of radiation incidents, and surveillance of radioactive contamination in the environment.”7 24×7 CCE Prep March 2013

Arif Subhan, MS, CCE, FACCE, is the chief biomedical engineer at the South Texas Veterans Health Care System, San Antonio; adjunct assistant professor, biomedical engineering, University of Connecticut; and a member of 24×7’s editorial advisory board. The suggestions and views expressed in this article are of the author. They do not represent the views of the Department of Veterans Affairs or the University of Connecticut.

Review Questions

1. Sources of radiation in a hospital may include ____.

a) Radioactive materials

b) Ionizing radiation generating devices

c) Nonionizing radiation generating devices

d) All of the above

2. The responsibilities of the Radiation Safety Committee include the following except ____.

a) Review occupational radiation exposure records of staff

b) Develop corrective action for radiation incidents

c) Review and approve the use of ionizing radiation sources

d) Review and approve the use of all ionizing and nonionizing radiation sources

3. The ____ committee has the overall responsibility for managing and developing polices and guidelines for the safe use of all sources of radiation.

a) Patient Safety

b) Environment of Care

c) Radiation Safety

d) Infection Control

4. According to the Nuclear Regulatory Commission, the Radiation Safety Committee must include all of the following except ____.

a) Radiation Safety Officer

b) A representative of management

c) A representative of the nursing service

d) Safety Officer

5. The following organizations have standards and regulations that require the safe use of radiation emission devices and radioactive materials except ____.

a) The Joint Commission

b) The FDA

c) The Nuclear Regulatory Commission

d) The National Institutes of Health

Answers: 1-d; 2-c; 3-c; 4-d; 5-d
References

1. Brigham and Women’s Radiation Safety Committee Charter. http://www.brighamandwomens.org/Departments_and_Services/radiology/Health%20Physics/RSC.aspx. Accessed February 3, 2013.

2. Nuclear Regulatory Commission. http://www.nrc.gov/about-nrc/governing-laws.html. Accessed February 5, 2013.

3. Strzelczyk J. In: JF Dyro, ed. Radiation Safety in Clinical Engineering Handbook. 2004.

4. Joint Commission. Hospital Accreditation Standards. 2013.

5. US Food and Drug Administration (FDA). http://www.fda.gov/AboutFDA/CentersOffices/OfficeofMedicalProductsandTobacco/CDRH/default.htm. Accessed February 4, 2013.

6. National Council on Radiation Protection and Measurements. http://www.ncrponline.org/AboutNCRP/Our_Mission.html. Accessed February 4, 2013.

7. California Department of Public Health. Radiologic Health Branch. http://www.cdph.ca.gov/programs/pages/radiologichealthbranch.aspx. Accessed February 4, 2013.