Public Notice on the Completion Environmental Protection Acceptance of the PET/CT Application Project at Dalian Jinshitan Hospital

Dalian Jinshitan Hospital PET / CT Application Project
Completion Environmental Protection Acceptance Monitoring Report Form

(Approval Version)

Construction Unit: Dalian Jinshitan Hospital

Prepared by: Liaoning Heyuan Environmental Technology Consulting Service Co., Ltd.

March 2020

Attachment 5: Notice on the Establishment of the Leading Group for Radiation Protection Work;

Dalian Jinshitan Hospital Document

Dajin Medical Character ( 2016) The 12th

@

Notice on the Establishment of the Hospital Radiation Protection Leading Group

To all departments:

According to the "Law of the People's Republic of China on the Prevention and Control of Radioactive Pollution" and the State Environmental Protection Administration.
Order No. 31, “Administrative Measures for the Safety Licensing of Radioisotopes and Radiation Devices,” and the competent superior authority
In accordance with the department’s relevant regulations, establish a management team for nuclear medicine quality and safety management at Dalian Jinshitan Hospital.
Lead the team and clearly define the division of responsibilities and duties.

One Establish a radiation protection leading group.

1. Members and Responsibilities of the Radiation Protection Leading Group

Team leader :
Deputy Team Leader :

Team members:

Director of the Radiology Department, Wangqing Mobile phone number ：13998569702

Deputy Director of the Pharmacy Department, Li Dongyue Mobile phone number ：13998679965

Liu Jun, Head of the Finance Department Mobile phone number ：15040590920

The team leader is the legal entity responsible for overall management. ) The dean serves as the head and is responsible for leading the radiation protection team.
Overall coordination and command of the group.

The deputy team leader, consisting of three associate deans, is responsible for the quality of nuclear medicine diagnosis, drug preparation, and drug administration, respectively.
Quantity and safety management work.

The team members include the head of the Medical Affairs Department, the head of the Logistics Support Department, and representatives from the Nuclear Medicine Department and the Pharmacy Department.
The director is responsible for the quality of nuclear medicine under both routine and emergency conditions, according to their official duties, authority, and scope of work.
The formulation of systems and the implementation of protective measures in the areas of safety management must work in tandem to ensure nuclear...
Medical quality and safety management work is being implemented smoothly. Ensuring communication and coordination among the hospital, higher-level authorities, and various departments.
Smooth communication and liaison channels between staff at all levels.

2. Establish a leading group for nuclear medicine quality and safety management within the department.

Team Leader: Director of the Radiology Department, Wang Qing
Deputy Team Leader ： Teng Yinwei, Deputy Director of the Radiology Department
Team Member: Du Hairu, Radiologist
Cai Qi, Radiologist
Wang Jiali, Radiologist
Li Ni, Radiologist
The team leader is appointed by the department director and operates under the guidance of the hospital’s Nuclear Medicine Quality and Safety Management Team.
Next, be responsible for designating the nuclear medicine quality within the department. S Organize and implement in conjunction with the safety management system. Deputy Team Leader
To be led by the deputy director of the department and senior experts, under the leadership of the department director, and in accordance with the hospital’s quality and safety standards.

(2) Responsibilities of the Leading Group for Radiation Safety and Environmental Protection:

1. Organizational Management Structure and Phone Numbers

2. Responsibilities of the Leading Group for Radiation Safety and Environmental Protection Work

2. The team leader is the dean, who is responsible for overall management and oversees radiation health protection.
Overall coordination and command 。

2. The two deputy team leaders are the vice presidents in charge of medical affairs, logistics, and other related tasks. They are responsible for radiation...
Medical treatment and security protection, among other tasks, in shooting safety incidents.

2. The 3 members are the directors of departments such as the Medical Affairs Department, Logistics Support Department, Radiology Department, and Pharmacy Department.
Assume responsibility for radiation health protection under both routine and emergency conditions, in accordance with job duties, authorities, and scope of work.
The formulation of management systems and the implementation of protective measures should be mutually coordinated to ensure radiation safety management.
reason Work smoothly. Implement effectively. Ensure smooth communication and coordination between the hospital, its superior authorities, and departmental staff.
Through channels Smooth.

4 subjects A departmental radiation unit needs to be established. Shooting safety With environmental protection workers Leading Group: The group leader shall be...
science Department Director To serve as; to hold the position of; to assume. In-hospital radiation Shooting safety With the environment Under the command of the leading group for protection work, responsible...
You are to establish and implement a leading group system for radiation safety and environmental protection work within your department. Based on...
Develop the department’s work regulations and operating procedures based on job responsibilities and scope of work. Ensure radiation protection.
To ensure the smooth and lawful conduct of nursing work.

2. 5. The Department of Radiology shall develop operational procedures for the management of radiation sources, quality control measures, and radiation source registration.
Relevant regulations regarding record-keeping, transport management, and the recovery of radioactive sources after patient death.

2.6 The Prevention Office is responsible for training, medical examinations, radiation safety, and radiation protection for hospital radiation workers.
Coordinate the application process for management and new, renovated, and expanded projects, and conduct regular inspections of personnel engaged in radioactive activities.
Radiation safety and protection work in the Isotope and Radiation Device Department. Responsible for developing hospital-related procedures.
Report to the higher-level environmental protection authorities and health administrative departments in the event of institutional incidents or emergencies.

2. 7. The Security Department is responsible for the security protection of radiation sources and radiation work environments; it is also responsible for emergency response.
Reporting to the competent authorities, public security departments, and other relevant agencies upon the occurrence of the incident; on-site security protection; and evacuation of personnel.

(3) Principles to be Followed in Emergency Rescue for Radioactive Accidents

Principle of Rapid Reporting:

Principle of Proactive Rescue:

The First Principle of Life;

The principle of scientific rescue, controlling the source of danger, and preventing the accident from escalating:

The principle of preserving the crime scene and collecting evidence.

(Four) Management System and Emergency Reporting Procedures

1. Strictly implement our institute’s “Regulations on Radiation Safety and Protection Management,” and engage in radiation-related activities. T
Staff members may only start working after undergoing training, and when on duty, they must strictly follow the operating procedures to avoid radiation incidents.
Therefore, it occurs.

2. Reporting Procedure: After an incident occurs or is discovered in the department, immediately report to the on-duty supervisor and hospital administration.
Department (0411-87902617), Report level by level Gao Yuan Fu Leadership Group for Shooting Safety and Environmental Protection Work ,
And in Report to the superior environmental protection authority as soon as possible within 1 hour. Health master Management departments, public security departments, involved in...
And radioactive pharmaceuticals shall also be reported simultaneously to the drug administration department.

3. Once A radiation accident has occurred; the department involved in the accident is under hospital radiation control. Safety and Environmental protection work
Under the leadership of the leading group, the following measures will be taken:

3.1、 Stand Immediately evacuate Regarding work Staff, secure the scene: Cut one May potentially expand the contamination.
The stage of the infection's spread. The monitoring authorities shall not lift the lockdown until the monitoring results show that the safety threshold has been reached.

3. 2. Immediately implement temporary isolation and emergency rescue measures for personnel who may have suffered radiation injury.
Shi, quickly identify the radioactivity. Isotope the type, activity, range, and degree of contamination.

3.3, In environmental protection , hygiene Under the guidance of higher authorities such as public security departments, take effective measures.
Safety protection measures, organized personnel to thoroughly remove contamination, and implement other medical treatments and rescue operations.
Measures.

3.4, In the event of loss or theft of a radioactive source, the scene should be properly secured and reported immediately.
The Security Department, the Pharmacy Department, and the Prevention Office shall each submit their reports separately to their superior authorities.
Relevant departments will assist in the investigation and handling.

(5) Procedures for Handling Radiation Health Incidents

1. Emergency procedures to be taken in the event of an accident: The department shall immediately report in the fastest possible manner.
Institute of Radiation Safety and Environmental protection Nursing work Leading group and relevant departments: Halt on-site operations,
Close the site, Cut one Cut off any links that could expand the scope of contamination, clear the pathways, and withdraw. Relevant to
Working person Employee

2. Radiation Safety and Environmental Protection Work Leadership small The group will convene professionals to conduct an investigation.
According to specifics The situation is being rapidly formulated. Accident scene Rational plan. In Take effective personal safety protection measures.

Under the circumstances, personnel shall thoroughly remove contamination, secure the accident site, and preserve the accident-related materials.
Equipment and instruments. The investigation team shall adhere to the principle of seeking truth from facts when determining the time and location of the accident.
Conduct a detailed investigation and analysis of the causes, the course of events, the extent of personal injuries, and the extent of property damage, and...
Carefully prepare and keep the investigation records properly. Promptly organize medical treatment for those who may be at risk.
The crowd was immediately isolated, and temporary isolation and emergency rescue measures were implemented, while health checks were conducted simultaneously.
Medical observation.

3. The Leading Group for Radiation Safety and Environmental Protection shall submit and prepare an accident report.
Surface materials, while also assisting the environmental administration and public security departments in accident investigation, handling, and other related tasks.
Matters concerning this aspect.

4. After handling various types of accidents, it is essential to organize relevant personnel to analyze the causes of the accident, starting from...
Draw lessons from the incident and take measures to prevent similar accidents from happening again.

5、 All relevant departments throughout the hospital are required to unconditionally cooperate with the functional departments in implementing the transfer of injured patients and...
For emergency medical rescue, the emergency department must establish a fast-track green channel to ensure rapid transport of injured patients and medical care.
Implementation of medical rescue. At the same time, leaders and staff of relevant hospital departments are required to demonstrate a high sense of responsibility.
Be conscientious and firmly prevent underreporting and delayed reporting. Actively cooperate with the environmental protection, public security, and health authorities.
Investigate the accident, provide relevant documentation, and implement the measures required by the relevant departments at higher levels.

6. Nuclear Medicine Radioactive Contamination Treatment Measures:

1. In the event of open-source liquid radionuclide contamination or particle source leakage, strict personal protective equipment must be worn.
Protective supplies, and use highly absorbent toilet paper, cotton, gauze, etc., to wrap from the periphery inward.
Adsorb and blot dry until completely clean: Wipe from the outer perimeter toward the center using a cloth dampened with cleaning solution; contaminated items should be collected in one place.
Store in a dedicated radioactive waste repository; if skin is contaminated, rinse the contaminated skin with warm water.
Then, repeatedly scrub with plain soapy water. 2-3 Next, TJ Replace immediately upon first sign of contamination; contaminated.
Items must not be taken out of the contaminated area: If the contaminated area still has high levels of radioactivity, the site must be sealed off. . Until
Environmental protection and public health surveillance personnel may only be released from quarantine after passing the required inspections.

6.2 In the event of an emergency involving excessive radiation exposure to humans, the affected individuals should be promptly arranged for medical treatment.
Undergo medical examinations or receive treatment at designated medical institutions, while simultaneously implementing emergency safety measures to address the source of danger.
Handling measures.

6. 3. Radioactive waste should be placed in separate bins according to its type of radioactivity and half-life duration.
Place it in a waste bag and clearly label it with the radioactive type and date of storage. Radioactive waste should be placed in a decay pool.
The duration shall not be less than 10 half-lives, with irregular disposal based on the amount of material remaining in the decay pool.
Note: Before disposal, the material must be tested and confirmed by the relevant authorities, and then treated as general medical waste.

Attachment: Radiation Accident Reporting Phone Number:

Environmental Protection Department 12306

Public Security Bureau 110

Emergency phone 120

Job Responsibilities for Radiation Protection Positions

One 、 Establish a leading group for radiation safety and protection, which will be responsible under the leadership of the hospital dean. The entire hospital's
Monitoring and supervision of radiation safety protection Management.

II. The protection and leadership group conducts radiation safety inspections every quarter. Work progress Conduct an inspection, to Inspection result
If timely feedback is provided, penalties will be imposed in accordance with relevant regulations, and its rectification will be supervised.

Three 、 Negative Responsible for supervision The use of protective equipment by radiation workers and irradiated patients.
Condition.

Four, Regular supervision of individuals Human dose Pen wearing and supervision Test the situation and research Busy and palm Grip reduction
An effective method for reducing radiation exposure. Harm.

Five 、 Responsible for Supervision on Medical examinations and health monitoring for radiation workers before starting their posts, during their employment, and upon leaving their posts.
Protect the archive Establish.

Six 、 Organization Basic Knowledge of Radiation Safety Protection Training.

Seven, Adopt effective publicity methods to carry out thorough public awareness campaigns on radiation safety protection. Work.

Eight 、 Responsible for Prevention of Radiation Accidents and Reporting Procedures in the Event of an Accident •

201

5. When the radiation source is no longer in use, contact the manufacturer for disposal or have it handled by the provincial authorities.
Radioactive waste repository, and complete the record of decommissioning radioactive sources.

III. Radioactive Workplaces

1. Each radioactive facility must display the “Radioisotope Work Permit” and the “Radio…”
Photocopy of the “Registration Certificate for Isotope Work” 0

2. Each radioactive laboratory entrance must be equipped with... M Radioactive markers and necessary protective measures
Full interlock and alarm system H Alternatively, work signals and radiation safety operating procedures must be posted on the wall, each in its designated place.
The Radiation Studio has dedicated personnel. Responsible.

3. When staff leave the source database, they must ensure that power and water are turned off, the door is locked, and all equipment is shut down.
Windows to prevent fires and theft. Source library managers must regularly inspect radioactive sources to ensure that records match the actual inventory.
Note: If discrepancies between accounts and physical items are found, The hospital should be notified promptly. In the event of theft of a radioactive source, it should be reported immediately.
Notify the relevant authorities.

4. Inspection :

The Director of the Radiotherapy Center and Nuclear Medicine is responsible for overseeing and inspecting the implementation of this standard.

The Equipment Department provides guidance and carries out publicity and education efforts, as well as conducts inspections to verify compliance with this standard.

(3) The Security Department is responsible for supervising the implementation of this standard and ensuring the security and protection of radioactive sources.

20 n^aJi

Radiation Safety Training System

To safeguard the occupational health and safety of radiation workers, in accordance with the "People's Republic of China"
The “Law on Prevention and Control of Occupational Diseases” and the “Regulations on Safety and Protection of Radioisotopes and Radiation Devices,” specifically...
Formulate this system.

One 、 Radiation workers must receive training in radiation protection and relevant legal knowledge before taking up their posts.
Only those who pass the training and assessment are eligible to take on the corresponding work.

Two 、 Regularly organize the radiation workers within this unit to receive training on radiation protection and relevant laws and regulations.
Regulatory knowledge training: The time interval between two training sessions for radiation workers shall not exceed. 2 years.

Three 、 Establish and properly maintain training records in accordance with the prescribed deadlines.

Radioactive Waste and Spent Source Disposal Plan

1. The handling of radioactive waste and spent sources shall be carried out strictly in accordance with the requirements of the established regulations. :

2. The handling of radioactive waste must be verified and approved by the laboratory’s responsible person before it can proceed.
Okay;

3. Single-use test tubes, plastic products, and other materials should be placed in black containers.
Place the disposable plastic bags in the storage room with time markings, and deliver them within the specified timeframe.
Unified incineration treatment in Shenyang City's incinerators:

4. Waste liquids from the experiment should be discharged into a dedicated decay pool for treatment; liquids containing radioactivity must not be disposed of in this manner.
The waste liquid from radiopharmaceuticals is treated in the same way as other wastewater and then discharged into the sewer system.

Say Bright

1. No results report. The official seal of the Analytical Testing Center and the special seal for Analytical Testing Reports are invalid.

2. No results report. The signature of the “report issuer” is invalid;

3. The results report cannot be altered arbitrarily; any report modified without prior review and approval is invalid.

4. The analytical test report is valid only for the samples that were entrusted.

5、 No part of this report may be reproduced without the written approval of this center.

6. If you have any objections to the report, you should submit them within [number] days from the date of receipt of the report. 15 Submit to our center within the same day;

7. The remaining samples and duplicate samples shall be handled according to the arrangements agreed upon at the time of sample receipt. , one Under normal circumstances, the secondary sample is retained for three months. :

8. Copies of the results reports and original test records will be retained at this center for six years.

Unit Name Northeast Analytical Testing Center of the Nuclear Industry
Unit address: Liaoning Xiaoxin Street, Shenbei New Area, Shenyang City, Liaoning Province 12 Number
Postal code: 110135

Business phone: 024— 89759525, 1301938 ⁷686
Complaint hotline: 13019387686, 024-86276510
Fax: 024— 89759560
E - mail : Wang Yux 9@163 .com

Three After injection, individuals rest in their respective resting positions; there is no cross-exposure. . Note Shooting prone
Fifty minutes later, the first person will go to the machine for a 20-minute checkup. If there are no special circumstances, they may leave.
If a delayed inspection is required, return to the original position and wait. At this point... , second Personal approval
Prepare for machine inspection, and so on.

Six, If this inspection involves four or more people, administer the injections at intervals. 20 points
Clock injection , the top three After injection, individuals rest in their respective resting positions, and there is no cross-exposure.
Injection 50 minutes later, the first person goes up. Machine inspection 20 minutes; depart unless there are special circumstances. After opening,
The second person gets on the machine. Check. At this point, the fourth person administers the drug injection, always ensuring that the internal level does not exceed the limit.
Pass three people , thereby Analogical reasoning.

seven 、 Add Strengthen the management of the internal call system, ensure... Certificate check The recovered patients quickly left.
And after completely leaving , down A sufferer The operator rises from the resting position, preparing to board the machine for inspection, thereby complying with regulations.
Avoid cross-traffic caused by people meeting. Irradiation.

Eight, All relevant staff must strictly comply. This system , protect Verify this system. Implement and carry out thoroughly,
Thus avoiding related cross-irradiation.

See the attached figure. 2. Current topographic maps of the project area