IAEA培训材料近年放射性事故分析.pptxVIP

IAEA Training CourseModule 2.10: Accident update – some newer events (UK, USA, France)QuestionsDo you think the accidents have not happened in recent years?Do you think well-developed centres are immune to these accidents?2021/7/4OverviewIt should be noted that the intent is certainly not to reflect the quoted centres in this presentation in poor lightInstead, the purpose is to draw lessonsIn many cases, the centres have a quality system in placeThe events are reconstructed from information in the public domain, and might differ from actual events due to gaps in this information.2021/7/4OverviewNewer examples of accidents in radiotherapy from 2004 to 20071st example: Incorrect manual parameter transfer (UK)2nd example: Reversal of images (USA)3rd example: Inappropriate measuring device (France)4th example: Erroneous calculation for soft wedges (France)5th example: Incorrect IMRT planning (USA)6th example: More information needed…2021/7/4IAEA Training Course1st example: Incorrect manual parameter transfer (UK)BackgroundJanuary 2006 at the Beatson Oncology Centre (BOC) in Glasgow, ScotlandAt the time: Radiotherapy physics staffing levels in Scotland less than 60% of the recommended level“Glasgow has problems with recruiting physicists, as shown by their high number of vacancies.”The Beatson OncologyCentre in Glasgow2021/7/4BackgroundTreatment planning at BOC:14.5 whole time equivalent (WTE) staff were available for between 4500 and 5000 new treatment plans per year.When staffing levels were compared with guidelines from IPEM, it was seen that 18 WTE staff would be the recommended level.2021/7/4BackgroundTreatment planning at BOC:Planning staff members and planning procedures were both categorizedA to C denotes senior to junior staffA to E denotes simple to complex plansThe main duties per staff category is outlined in column 4 Table from: “Report of an investigation by the Inspector appointed by the Scottish Ministers for The Ionising Radiation (Medica