Radiation (Laser)Management Plan
(EXAMPLE of the type of information expected. Practices are expected to
provide specific details e.g. about students/trainees and the courses that
they are undertaking. The Plan will be supported by practice protocols
and procedures, to be referenced in the plan but not submitted with it.)
For: / “Tasmanian Dermatology”Licence No: L/123456
For the practice of: / Dermatology - Laser Therapy
To be carried out at: / Tasmanian Dermatology Practice,
Consulting rooms 1,2 and 3 at 44 Brown StreetHobart and
Consulting rooms 1and 2 at 12 White Street Launceston.
These are registered places under the Tasmanian Radiation Protection Act 2005
Plan Prepared by: / Jane Smith
Practice Manager
Date: / October2006
Contact Details / Telephone: 03 62123456
Facsimile: 03 621654321
Email:
Plan accepted by Dr W. Smith (Director of “Tasmanian Dermatology”) who hereby agrees to adhere to all requirements of the plan
Signature:
Date:
Date for review: / October 2007
This Plan has been prepared in accordance with Regulation 8 of the Radiation Protection Regulations 2006. The purpose of this plan is to ensure that the practice of laser dermatology is conducted as safely as possible and in compliance with the Radiation Protection Act of 2005 and the Radiation Protection Regulations 2006.
Compliance with this radiation management plan will help ensure that the radiation doses to users, other persons involved in the treatment, members of the public and the environment are are as low as reasonably achievable. It will also help ensure that the number of people exposed to radiation and the likelihood of unexpected exposure to radiation are minimised.
The plan is to be read by all staff who participate in the laser treatment, at “Tasmanian Dermatology”
Information Required by Regulation 8
Radiation Protection Regulations 2006
a) brief description of the type and scope of the radiation practice / Dermatological treatments carried out by specialist physicians in Hobart and Launceston.
b) A list of the radiation sources dealt with at “Tasmanian Dermatology” / 10.6 um, 10 Watt “Las-Skin” Class 4.
c) An assessment of the potential hazards from the radiation sources dealt with in the consulting rooms / A Class IV laser can cause eye and skin injury by direct contact with the beam or by reflection of the beam from a reflective surface.
d) details of the environment likely to be exposed to radiation during the surgical procedure / Consulting rooms where Laser maybe in operation, and into adjacent areas through windows (see precautions for covering windows).
e) The radiation principles, work practices (including quality assurance procedures) and equipment (including personal radiation monitors) used to ensure that the radiation exposure of persons or the environment is as low as is reasonably achievable during typical types of work carried out within the radiation practice; / As the practice operates at two sites; namely Hobart and Launceston and employs 10 specialist physicians, a Laser Safety Committee (LSC), as recommended by AS/NZS 4173, has been formed by the practice. The committee meets every 6 months (or as needed) to review laser safety, clinical matters and on-going training needs for staff.
The Committee comprises Dr Smith, Ms Smith (LSO) and two specialist physicians.
The terms of reference for the LSC are in line with the requirements of AS/NZS 4173 and are maintained in the Hobart practice.
Appropriate safety goggles/ glasses with side panels are to be worn by all specialist physicians and patients within the consulting room when the laser is in operation.
Safety Signs are mounted on all doors leading into the consulting rooms.
Consulting room windows have opaque blinds.
Routine checks and pre test firing are to be performed as per the manufacturers instructions in the user’s manual
Restricted access to consulting rooms when laser in use.
f) details of the classes of persons likely to be exposed to radiation during the radiation practice, including
- Children; and
- Pregnant women; and
- Volunteers in biomedical research; and
- Persons exempt from section 13(1) of the Act under Part 10;
- Other Persons;
g) the maximum dose of radiation it is anticipated a person of a class of persons specified in paragraph (f) will receive while the radiation principles, work practices and equipment referred to in paragraph (e) are being used, and the action to be taken if those doses are exceeded; / X-Rays Nil
Laser Max Output 10 Watts
Wavelength 10.6 um
h) details of a course of study or training that is being undertaken or will be undertaken by a person who is expected to be dealing with a radiation source in the laser procedure; and requires , as part of that course of study or training, the person to deal with the radiation source in the radiation practice; / Laser Safety Course presented by an accredited laser engineer
i) the name, qualifications and experience of the supervisor of a person referred to in paragraph (h) (i) while undertaking that part of a course of study or training referred to in paragraph (h) (ii) / No students/ trainees present
j) the training and information to be provided to person involved in carrying out the radiation practice; / Laser Safety Officer must undergo relevant training
Laser users must undertake an accredited training course. It is practice policy to attend refresher courses every 3 years. The LSC will review this policy annually, based on the practice’s safety record.
k) the name and contact details of the radiation safety officer for the radiation practice; / Mrs Jane Smith (RN and LSO)
Telephone: 03 62123456
Facsimile: 03 621654321
Email:
l) a brief description of the role of the Radiation Safety Officer; / See attachment A at end of this Plan
m) a brief description of the resources available to the radiation safety officer to enable him or her to preform his or her role under the radiation management plan; / Budget includes funding for replacement of protective goggles as necessary
Laser safety training for relevant staff
And service contract of the laser
n) a description of the roles and responsibilities, that are relevant to a dealing with the radiation source in the radiation practice, of all persons authorised by the licence to deal with that radiation source in the radiation practice; / See attachment A
Other Staff - Obey signs and written instructions (developed and placed at each door to the consulting rooms), which are aimed at avoiding contact with laser beam.
LSC, to review laser safety and make recommendations to the practice on the effectiveness of safety procedures. The LSC also assesses the training, experience and accreditation of specialist physicians who may work with lasers in the practice.
o) the methods used to ensure that the persons referred to in paragraph n) are aware of their obligations under the Act and the licence; / Laser Safety awareness training to relevant staff by Laser Safety Officer
p)details of how the radiation source in the radiation practice will be prepared for use, repaired, maintained, transported, stored and disposed of; / Maintenance/service contract is in place for laser machine
6 monthly checking by a biomedical service engineer.
Laser machine will be disposed of in accordance with the Act,
a)such that it can not be reassembled for use, or
b)sold, or
c)traded in when no longer required.
q) details of any emergency response plans for the radiation practice including reporting to the Director of Public Health / Laser will be switched off/ unplugged immediately if problem suspected.
DPH will be informed of any malfunction of the laser Apparatus that could have resulted in unexpected laser beam damage of any person or of any situation where a person could have been exposed inadvertently
r)details of procedures that are designed to minimise the radiation hazard arising from a radiation incident; / See protocols in (q) above.
s)details of reporting procedures for incidents adversely affecting, or likely to adversely affect-
- equipment used in the radiation practice; or
- the environment; or
- the health and safety of any person.
Refer to “Tasmanian Dermatology” “OHS Procedures and Incident Reporting” for Incident Reporting Process and Standard Forms.
t)details of record keeping requirements including details of the records that will be kept of movement of any mobile radiation source in the radiation practice; / Laser log book which documents and details and procedures for is maintained. Separate Log book is kept for any repairs and maintenance undertaken on the laser
u) details of the use of radiation warning signs and labels in the radiation practice. / Warning labels are on the Laser machine and on the consulting room doors indicating that the Laser will be used within. The certificate of registration for the consulting rooms requires this.
Referenced Documents:
- Tasmanian Radiation Protection Regulations 2006.
- Tasmanian Radiation Protection Act 2005.
- Australian Standard AS/NZS 4173-1994 Guide to the safe use of Lasers in the Healthcare.
- Tasmanian Dermatology – Laser Safety Committee terms of reference.
- Tasmanian Dermatology –Procedures and Incident Reporting.
Attached Documents:
- Duties of Laser Safety Officer.
- List of Laser machine (licence schedule/application form).
- List of authorized users (licence schedule/application form).
ATTACHMENT A
Laser Safety Officer
“Tasmanian Dermatology”
Duties of :-
a)Maintain Register of licensed Medical Practitioners able to use Laser Apparatus
b)Maintain Register of licensed Nursing Staff able to operate Laser Apparatus
c)Supervise the radiation protection aspects as specified in Radiation management plan
d)Ensure that Planned Maintenance and Service Contracts are kept on Schedule, and records are maintained
e)Ensure Log book of use of Laser Apparatus with recording of patient mane, procedure and details of laser settings
f)Ensure that all lasers and laser systems used in the practice facility are correctly classified according to AS 2211
g)Investigate all incidents and accidents involving lasers
h)Ensure all Laser practices within the consulting rooms are within the parameters of Australian Standard AS/NZS 4173:1994 Guide to the safe use of lasers in health care.
Health Physics Branch90 Davey Street
Hobart Tas 7001 / Phone 03 6222 7256
Fax 03 6222 7257
Email / H19575 Form RPA0316
Issued: October2006
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