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Excerpt
This report recounts an examination of a radiological accident that occurred in Bialystok, Poland, in February 2001. The accident resulted in severe overexposure of five female patients who were undergoing post-operative radiotherapy following breast surgery.
The accident resulted from the transitory loss of electrical power to the accelerator used for the radiation treatment of one patient. Subsequently, four other patients were treated in the facility. The overexposure to all of them was found to be caused by the failure of the interlock system as well as a defective fuse in the dose monitoring system.
IAEA dispatched two investigating teams: one to assess the quality and appropriateness of the medical procedures used following the accidents, the other to perform a dose reconstruction for each patient. These assessments are described in considerable detail, as well as the medical follow-up of the patients and a description of the subsequent, immediate medical histories. Three of the patients received doses of the order of 60–80 Gy.
The main value of this report for the health physicist lies in the detailed description of methodology used for dose reconstruction using several independent dosimetry methods. For the medical reader discussion of various clinical and surgical procedures to alleviate radiation damage should be of interest.
The overall message is, of course, the need to check operability of all accelerator monitors and dosimeter systems routinely before any patient exposure will occur, especially after unexpected interruptions or temporary shutdown of the facility. The report provides a number of procedural and regulatory recommendations.
