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Viewing: Anatomic Pathology Radiation Safety

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Current Status: Active PolicyStat ID: 10677722

Origination: | 11/5/2021
Effective: | 11/5/2021
Last Approved: | 11/5/2021
Last Revised: | 11/5/2021
Next Review: | 11/5/2023
Document Contact: | Jennie Green: Mgr Laboratory
Area: | Laboratory-Safety
Key Words: |
Applicability: | Grosse Pointe, Royal Oak, Troy

Anatomic Pathology Radiation Safety

Document Type: Procedure

PURPOSE AND OBJECTIVE:

This policy delineates the procedures used for the safe handling of radioactive materials and specimens in the Anatomic Pathology Laboratory.

DEFINITIONS:

Ionizing radiation:  form of energy that can overcome the binding energy of electrons in their orbits, producing ions, which can cause DNA changes that may increase the potential for cancer to occur

Radioactive Material:  Any material that emits ionizing radiation.

GENERAL RADIATION SAFETY PROCEDURES:

General Safety

Before implementing any new procedures or using any new radioactive materials (RAM), contact the Radiation Safety Officer (RSO).  There are specific requirements for the ordering, storing and use of RAM.

Always use an absorbent paper on a tray when working with radioactive material.  The tray should be capable of containing the entire volume of liquid in case of a spill.

No pipetting by mouth, licking of labels, eating drinking, smoking or applying cosmetics in the laboratory.

Laboratory work stations, containers, and areas where radioactive materials are handled should be kept clean so that potential spills are readily seen.

Personal Protective Equipment (PPE)

Refer to Laboratory Personal Protective Measures.

Monitoring

Radiation badge monitoring can be requested at any time by a manager, supervisor or an employee.

Spills

Refer to Radioactive Material Spill Response.

Decontamination

Refer to Decontamination Procedures for Personal Radiation Contamination.

POTENTIAL RADIOACTIVE CHEMICALS/SOURCES:

Technetium (Tc-99m)-Sentinel lymph node, breast lumpectomy, breast mastectomy, skin melanoma excision

Used to identify sentinel lymph nodes in patients with breast cancer or skin melanomas, looking for lymphatic metastasis

All tissues containing Tc-99m are to be handled according to typical procedures.  No special precautions are needed.

Note:  Radiation monitoring was conducted several times at both Royal Oak and Troy Anatomic Pathology (AP), where testing levels are highest, by the RSO, with tissue received in Surgical Pathology (accessioning and grossing) and Cytology.  Findings detected no significant radiation above background levels.

Radioactive Seeds

Refer to Radiation Safety Procedures for Radioactive Seeds Excised from a Tissue Sample.

Uranyl Acetate, Uranyl nitrate

Refer to Radiation Safety Precautions for the Use of Uranyl Chemicals.

Electron Microscope

The electron microscope (EM scope) contains a tungsten filament that is producing electrons (x-rays).  The EM scope is self-shielded so exposure of the technologist during operation is typically background levels.  Levels of exposure must be periodically monitored.

Electron microscopes are exempt from the following radiation safety precautions if the instrument is not capable of exceeding an operating potential of 50 kilovolts.

Electron Microscope must:

Be labeled "Caution:  Radiation-This equipment produces x-radiation when energized".

Be operated only by trained personnel

Have operating procedures posted near the equipment

Have periodic radiation surveys done by the Radiation Safety Officer:

annually

after major service

EM scope cannot be used until the survey is complete and the results posted

Changing of the filament is not considered major service

If a new Electron Microscope is received, the EM scope cannot be used until the survey is complete and the results posted.

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Approval Signatures

Step Description | Approver | Date
Medical Directors | Mitual Amin: Chair, Pathology - OUWB | 11/5/2021
Medical Directors | Ann Marie Blenc: System Med Dir, Hematopath | 11/4/2021
Medical Directors | Vaishali Pansare: Chief, Pathology | 11/4/2021
Policy and Forms Steering Committee (if needed) | Jennie Green: Mgr Laboratory | 11/4/2021
Policy and Forms Steering Committee (if needed) | Ilene Hirsch: Project Mgr Policy | 11/4/2021
Operations Directors | Joan Wehby: Dir, Lab Operations C | 11/4/2021
Operations Directors | Brittnie Berger: Dir, Lab Operations C | 11/3/2021
Operations Directors | Elzbieta Wystepek: Dir, Lab Operations B | 11/3/2021
Operations Directors | Amy Knaus: Dir, Lab Operations C | 11/3/2021
| Jennie Green: Mgr Laboratory | 11/3/2021

Step Description | Approver | Date
Medical Directors | Mitual Amin: Chair, Pathology - OUWB | 11/5/2021
Medical Directors | Ann Marie Blenc: System Med Dir, Hematopath | 11/4/2021
Medical Directors | Vaishali Pansare: Chief, Pathology | 11/4/2021
Policy and Forms Steering Committee (if needed) | Jennie Green: Mgr Laboratory | 11/4/2021
Policy and Forms Steering Committee (if needed) | Ilene Hirsch: Project Mgr Policy | 11/4/2021
Operations Directors | Joan Wehby: Dir, Lab Operations C | 11/4/2021
Operations Directors | Brittnie Berger: Dir, Lab Operations C | 11/3/2021
Operations Directors | Elzbieta Wystepek: Dir, Lab Operations B | 11/3/2021
Operations Directors | Amy Knaus: Dir, Lab Operations C | 11/3/2021
| Jennie Green: Mgr Laboratory | 11/3/2021
Older Version Approval Signatures

Applicability

Grosse Pointe, Royal Oak, Troy

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