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Radiation Accidents and Malicious Events – Scenarios and Scope of the Work of ICRP Task Group 120

The International Commission on Radiological Protection (ICRP) Task Group 120 (TG120) is developing ICRP recommendations for radiological protection for a wide range of radiation accidents and malicious events, complementing those given in ICRP Publication 146 (2020) for large nuclear accidents. The scope includes accidents involving criticalities, operating faults, and fires and explosions in nuclear facilities, inadvertent damage to sealed radiation sources, as well as malicious events, such as sabotage of nuclear facilities or materials, use of radiological dispersal devices, the contamination of food and drinking water supplies, and the deployment of nuclear weapons. A template has been designed to collate relevant information on a wide range of case studies and hypothetical malicious scenarios to ensure that the recommendations developed are broadly applicable and comprehensive. For all scenarios, a graded approach to protection is being taken, accepting that specific guidance may be required for some distinctive aspects, for example, protection during times of armed conflict. This paper provides an overview of the scenarios and scope of the work of TG120, including some of the radiological and non-radiological impacts of radiation emergencies, along the response and recovery timeline.

ICRP↗

REAC/TS Radiation Accident Registry: An Overview

Over the past four years, REAC/TS has presented a number of case reports from its Radiation Accident Registry. Victims of radiological or nuclear incidents must meet certain dose criteria for an incident to be categorized as an “accident” and be included in the registry. Although the greatest numbers of “accidents” in the United States that have been entered into the registry involve radiation devices, the greater percentage of serious accidents have involved sealed sources of one kind or another. But if one looks at the kinds of accident scenarios that have resulted in extreme consequence, i.e., death, the greater share of deaths has occurred in medical settings.

61 RADIATION PROTECTION AND DOSIMETRY↗

Nuclear Thermal Rocket (NTR) Development Risk Communication

There are clear advantages of development of a Nuclear Thermal Rocket (NTR) for a crewed mission to Mars. NTR for in-space propulsion enables more ambitious space missions by providing high thrust at high specific impulse (approximately 900 sec) that is 2 times the best theoretical performance possible for chemical rockets. Missions can be optimized for maximum payload capability to take more payload with reduced total mass to orbit; saving cost on reduction of the number of launch vehicles needed. Or missions can be optimized to minimize trip time significantly to reduce the deep space radiation exposure to the crew. NTR propulsion technology is a game changer for space exploration. However, "NUCLEAR" is a word that is feared and vilified by some groups and the hostility towards development of any nuclear systems can meet great opposition by the public as well as from national leaders and people in authority. Communication of nuclear safety will be critical to the success of the development of the NTR. Why is there a fear of nuclear? A bomb that can level a city is a scary weapon. The first and only times the Nuclear Bomb was used in a war was on Hiroshima and Nagasaki during World War 2. The "Little Boy" atomic bomb was dropped on Hiroshima on August 6, 1945 and the "Fat Man" on Nagasaki 3 days later on August 9th. Within the first 4 months of bombings, 90- 166 thousand people died in Hiroshima and 60-80 thousand died in Nagasaki. It is important to note for comparison that over 500 thousand people died and 5 million made homeless due to strategic bombing (approximately 150 thousand tons) of Japanese cities and war assets with conventional non-nuclear weapons between 1942- 1945. A major bombing campaign of "firebombing" of Tokyo called "Operation Meetinghouse" on March 9 and 10 consisting of 334 B-29's dropped approximately1,700 tons of bombs around 16 square mile area and over 100 thousand people have been estimated to have died. The declaration of death is very clear for conventional weapons and then the declaration of death due to radiation becomes vague and unclear. This may have been due to people mis-understanding the dangers and effects of radiation when assessing the damage and harm to people initially, but it is also become insidious when expressing opposition to nuclear energy. A nuclear radiation accident can be scary due to the power involved and the fear of radiation release. The International Atomic Energy Agency defines a nuclear and radiation accident a "an event that has led to significant consequences to people, the environment or the facility." There have been 3 commercial nuclear reactor accidents (Chernobyl, Three Mile Island, and Fukushima) that stand out to the public and much of the information about the result and impact to workers, environment, and public can be misleading. Often information is presented without clear correlation with radiation and other pertinent information is left out presenting a very scary situation to affect the emotions of the reader. A very boring but "critically acclaimed" movie was made in 1979 called "The China Syndrome" starring Jane Fonda and Jack Lemmon. The film was released on March 16, 1979, 12 days before the 3-Mile Island nuclear accident in Pennsylvania. The basis from the movie was from a few nuclear plant incidents and in particular, the Brown's Ferry Alabama Power Plant fire. In one scene from the movie, a physicist Dr. Elliott Lowell played by Donald Hotton states that a China Syndrome event would make "an area the size of Pennsylvania" permanently uninhabitable. Real serious nuclear incidents like Chernobyl and Fukushima are often sited to make people fear the consequences of using nuclear power. However, the consequences are at best poorly communicated and at worst fictitiously inflated to instigate social unrest against nuclear power. There is an article being circulated on Facebook with a title "28 Signs that the (US) West Coast is being absolutely fried with nuclear radiation from Fukushima" which focus on mis-information and fear mongering. Nuclear power and NTR are powerful resources that can open many doors for future prosperity and capability. With great power comes great responsibility. Radiation and its effects need to be better understood, quantified, and communicated. A human mission to mars has its own risks of deep space radiation and is considered a considerable risk at 400 milli-Sieverts per year in deep space and 245 milli-Sieverts per year on the surface of Mars as measured by the Mars Curiosity mission. Although these quantities of ionizing radiation are within the astronaut career limit, it exceeds the yearly average amounts of ionizing radiation. Astronaut crews have experienced these levels of radiation before, but for durations shorter than a year, and a mission to Mars could possibly be 3 years in length. There is also evidence that people can comfortably handle higher levels of ionizing radiation where the radiation occurs naturally like Ramsar, Iran when people can experience 270 milli-Sieverts per year. A risk posture that the development, test, and flight of an NTR will meet opposition from groups who oppose nuclear energy must be likely and the impact can be sever to the effort. Active risk mitigation must be taken for an NTR full-scale development project. The NTR design must take into account safety for transport and off nominal conditions. Nuclear fuel element must consider containment of fission products and Low Enriched Uranium (LEU) that may meet less opposition should be considered for safety and security reasons. Even though testing was conducted on Rover/NERVA safely and successfully in the 60's with exhaust sent heavenward in to open air, modern testing of NTR must consider full containment and no release of ionizing radiation to the public and must meet the current requirement of no more than 0.1 milli-Sieverts per year to the public. 0.1 milli-Sieverts is equivalent to eating one banana or a 20 hour plane flight. Good communication with the public and regulatory agencies will be essential to show that all effort is applied toward protection to the public and astronauts. The inspiring endeavor to put humans on Mars to study the planet, search for life, and learn more about this Solar System will be full of risks but it will be worth it. NTR will be worth the development effort if it allows humans to explore our Solar System.

Kim, Tony↗

Innovative Process for Comprehensive Treatment of Liquid Radioactive Waste - 12551

This paper presents the results of research activities aimed at creation of a principally new LRW distilling treatment method. The new process is based on the instantaneous evaporation method widely used in distillation units. The main difference of the proposed process is that the vapor condensation is conducted without using heat exchangers in practically ideal mode by way of direct contacting in a vapor-liquid system. This process is conducted in a specially designed ejector unit in supersonic mode. Further recuperation of excess heat of vaporization is carried out in a standard heat exchanger. Such an arrangement of the process, together with use of the barometric height principle, allows to carry out LRW evaporation under low temperatures, which enables to use excess heat from NPS for heating initial LRW. Thermal calculations and model experiments have revealed that, in this case, the expenditure of energy for LRW treatment by distilling will not exceed 3 kilowatt-hour/m{sup 3}, which is comparable with the reverse-osmosis desalination method. Besides, the proposed devices are 4 to 5 times less metal-intensive than standard evaporation units. These devices are also characterized by versatility. Experiments have revealed that the new method can be used for evaporation of practically any types of LRW, including those containing a considerable amount of oil products. Owing to arrangement of the evaporation process at low temperatures, the new devices are not sensitive to 'scale formation'. This is why, they can be used for concentrating brines of up to 500-600 g/l. New types of such evaporating devices can be required both for LRW treatment processes at nuclear-power plants under design and for treating 'non-standard' LRW with complex physicochemical and radionuclide composition resulting from the disaster at the Fukushima I Nuclear Power Plant.) As a result of accidents at nuclear energy objects, as it has recently happened at NPP 'Fukushima-1', personnel faces the necessity to take emergency measures and to use marine water for cooling of reactor zone in contravention of the technological regulations. In these cases significant amount of liquid radioactive wastes of complex physicochemical composition is being generated, the purification of which by traditional methods is close to impossible. According to the practice of elimination of the accident after-effects at NPP 'Fukushima' there are still no technical means for the efficient purification of liquid radioactive wastes of complex composition like marine water from radionuclides. Therefore development of state-of-the-art highly efficient facilities capable of fast and safe purification of big amounts of liquid radioactive wastes of complex physicochemical composition from radionuclides turns to be utterly topical problem. Cesium radionuclides, being extremely dangerous for the environment, present over 90% of total radioactivity contained in liquid radioactive wastes left as a result of accidents at nuclear power objects. For the purpose of radiation accidents aftereffects liquidation VNIIHT proposes to create a plant for LRW reprocessing, consisting of 4 major technological modules: Module of LRW pretreatment to remove mechanical and organic impurities including oil products; Module of sorption purification of LWR by means of selective inorganic sorbents; Module of reverse osmotic purification and desalination; Module of deep evaporation of LRW concentrates. The first free modules are based on completed technological and designing concepts implemented by VNIIHT in the framework of LLRW Project in the period of 2000-2001 in Russia for comprehensive treatment of LWR of atomic fleet. These industrial plants proved to be highly efficient and secure during their long operation life. Module of deep evaporation is a new technological development. It will ensure conduction of evaporation and purification of LRW of different physicochemical composition, including those containing hardness salts, resulted in generation of LRW concentrate 300-600 g/l. The method is based on utilization of supersonic ejector for intensification of thermal physic processes and performance of evaporation in brine recycling mode. All proposed technological solutions are totally based on patented Russian developments. Proposed work will allow to construct modular plants, which will be totally prepared for efficient purification of any types of liquid radioactive wastes from radionuclides in case of force majeure. According to proposed scheme concentration level of cesium radionuclides in safe-for-storage form will make up not less than 5000. With respect to purification from cesium radionuclides of liquid radioactive wastes stored at NPP 'Fukushima' about 10 t of inorganic sorbents, loaded in 160 protective filter-containers, will be required for solving this problem. The amount of secondary wastes will be reduced approximately in 5 times in comparison with traditional schemes, applied in purification of secondary LRW of Fukushima-1 by Areva (France) and Kurion (USA) companies. All units of modular plants will be constructed and manufactured as totally automated, providing their twenty-four-hour safe operation. Modular design will ensure efficiency and let optimize the costs of secondary LRW treatment. In order to ensure off-line operation in emergency conditions the plant should be equipped with auxiliary modules: energy and ventilation ones. Under normal conditions these modules can be stored in 'mothballed' condition at special warehouses under the authority of federal bodies. It will be reasonable to choose required transport facilities, the most suitable for transportation of modules to target destination beforehand, using vessel classification list.

12 MANAGEMENT OF RADIOACTIVE AND NON-RADIOACTIVE W↗

Level-3 Probabilistic Safety Analysis VAB-3 as an NPP Safety Enhancement Stage

Questions pertaining to the development of reactors from the standpoint of the evolution of protection and emergency response systems for large radiation accidents, and development of probabilistic safety analysis at different levels are examined. Examples are presented of the calculation of quantitative characteristics of risk in an accident at a model NPP that show the possibility of using VAB-3 to evaluate the scale of countermeasures as a function of the level of intervention, their effectiveness as a function of the time of application and validation of countermeasures for an individual populated point. It is shown that the VAB-3 methodology must be developed in order to increase NPP safety.

22 GENERAL STUDIES OF NUCLEAR REACTORS↗

Estimate of radiation release from MIT reactor with un-finned LEU core during Maximum Hypothetical Accident

The Massachusetts Institute of Technology Reactor (MITR-II) is a research reactor in Cambridge, Massachusetts designed primarily for experiments using neutron beam and in-core irradiation facilities. At 6 MW, it delivers neutron flux and energy spectrum comparable to light water reactor (LWR) power reactors in a compact core using highly enriched uranium (HEU) fuel. In the framework of nonproliferation policy, the international community aims to minimize the use of HEU in civilian facilities. Within this context, research and test reactors have started a program to convert HEU fuel to low enriched uranium (LEU) fuel. A new type of LEU fuel based on a high density alloy of uranium and molybdenum (U-10Mo) is expected to allow the conversion of U.S. domestic high performance reactors like MITR. The current study focuses on the impacts of MITR Maximum Hypothetical Accident (MHA), which is also the Design Basis Accident (DBA), with LEU fuel. The MHA for the MITR is postulated to be a coolant flow blockage in the fuel element that contains the hottest fuel plate. It is assumed that the entire active portion of five fuel plates melts. The analysis shows that, within a 2-h period and by considering all the possible radiation sources and dose pathways, the overall off-site dose is 302.1 mrem (1 rem ¼ 0.01 Sv) Total Effective Dose Equivalent (TEDE) at 8 m exclusion area boundary (EAB) and a higher dose of 392.8 mrem TEDE is found at 21 m EAB. In all cases the dose remains below the 500 mrem total TEDE limit goal based on NUREG-1537 guidelines.

Sun, Kaichao (ORCID:0000000285871918)↗

Radiation-induced Genomic Instability and Radiation Sensitivity

The obvious relationships between reactive oxygen and nitrogen species, mitochondrial dysfunction, inflammatory type responses and reactive chemokines and cytokines suggests a general stress response induced by ionizing radiation most likely leads to the non-targeted effects described after radiation exposure. We argue that true bystander effects do not occur in the radiation therapy clinic. But there is no question that effects outside the target volume do occur. These “out of field effects” are considered very low dose effects in the context of therapy. So what are the implications of non-targeted effects on radiation sensitivity? The primary goal of therapy is to eradicate the tumor. Given the genetic diversity of the human population, lifestyle and environment factors it is likely some combination of these will influence patient outcome. Non-targeted effects may contribute to a greater or lesser extent. But consider the potential situation involving a partial body exposure due to a radiation accident or radiological terrorism. Non-targeted effects suggest that the tissue at risk for demonstrating possible detrimental effects of radiation exposure might be greater than the volume actually irradiated.

Varnum, Susan M.↗

CBP/P300 Inhibitors Mitigate Radiation-Induced GI Syndrome by Promoting Intestinal Stem Cell-Mediated Crypt Regeneration

Radiation-induced gastrointestinal syndrome (RIGS) is currently the main cause of death for people exposed to a high dose of irradiation during nuclear incidents, and there is currently no approved effective therapy. Here, we found that CBP/P300 inhibitors, with high efficacy and low toxicity, might be promising radiation mitigators that can cure RIGS.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

Computer program for the sensitivity calculation of a CR-39 detector in a diffusion chamber for radon measurements

Computer software for calculation of the sensitivity of a CR-39 detector closed in a diffusion chamber to radon is described in this work. The software consists of two programs, both written in the standard Fortran 90 programming language. The physical background and a numerical example are given. Presented software is intended for numerous researches in radon measurement community. Previously published computer programs TRACK-TEST.F90 and TRACK-VISION.F90 [D. Nikezic and K. N. Yu, Comput. Phys. Commun. 174, 160 (2006); D. Nikezic and K. N. Yu, Comput. Phys. Commun. 178, 591 (2008)] are used here as subroutines to calculate the track parameters and to determine whether the track is visible or not, based on the incident angle, impact energy, etching conditions, gray level, and visibility criterion. The results obtained by the software, using five different V functions, were compared with the experimental data found in the literature. Application of two functions in this software reproduced experimental data very well, while other three gave lower sensitivity than experiment.

61 RADIATION PROTECTION AND DOSIMETRY↗

SU-E-T-310: Targeting Safety Improvements Through Analysis of Near-Miss Error Detection Points in An Incident Learning Database

Purpose: Radiation treatment planning involves a complex workflow that can make safety improvement efforts challenging. This study utilizes an incident reporting system to identify detection points of near-miss errors, in order to guide our departmental safety improvement efforts. Previous studies have examined where errors arise, but not where they are detected or their patterns. Methods: 1377 incidents were analyzed from a departmental nearmiss error reporting system from 3/2012–10/2013. All incidents were prospectively reviewed weekly by a multi-disciplinary team, and assigned a near-miss severity score ranging from 0–4 reflecting potential harm (no harm to critical). A 98-step consensus workflow was used to determine origination and detection points of near-miss errors, categorized into 7 major steps (patient assessment/orders, simulation, contouring/treatment planning, pre-treatment plan checks, therapist/on-treatment review, post-treatment checks, and equipment issues). Categories were compared using ANOVA. Results: In the 7-step workflow, 23% of near-miss errors were detected within the same step in the workflow, while an additional 37% were detected by the next step in the workflow, and 23% were detected two steps downstream. Errors detected further from origination were more severe (p<.001; Figure 1). The most common source of near-miss errors was treatment planning/contouring, with 476 near misses (35%). Of those 476, only 72(15%) were found before leaving treatment planning, 213(45%) were found at physics plan checks, and 191(40%) were caught at the therapist pre-treatment chart review or on portal imaging. Errors that passed through physics plan checks and were detected by therapists were more severe than other errors originating in contouring/treatment planning (1.81 vs 1.33, p<0.001). Conclusion: Errors caught by radiation treatment therapists tend to be more severe than errors caught earlier in the workflow, highlighting the importance of safety checks in dosimetry and physics. We are utilizing our findings to improve manual and automated checklists for dosimetry and physics.

60 APPLIED LIFE SCIENCES↗

SU-E-T-469: Implementation of VAs Web-Based Radiotherapy Incident Reporting and Analysis System (RIRAS)

Purpose: This Web-based Radiotherapy Incident Reporting and Analysis System (RIRAS) is a tool to improve quality of care for radiation therapy patients. This system is an important facet of continuing effort by our community to maintain and improve safety of radiotherapy.Material and Methods: VA’s National Radiation Oncology Program office has embarked on a program to electronically collect adverse events and good-catch data of radiation treatment of over 25,000 veterans treated with radiotherapy annually. This VA-Intranet based software design has made use of dataset taxonomies and data dictionaries defined in AAPM/ASTRO reports on error reporting. We used proven industrial and medical event reporting techniques to avoid several common problems faced in effective data collection such as incomplete data due to data entry fatigue by the reporters, missing data due to data difficult to obtain or not familiar to most reporters, missing reports due to fear of reprisal etc. This system encompasses the entire feedback loop of reporting an incident, analyzing it for salient details, and developing interventions to prevent it from happening again. The analysis reports with corrective, learning actions are shared with the reporter/facility and made public to the community (after deidentification) as part of the learning process. Results: Till date 50 incident/good catches have been reported in RIRAS and we have completed analysis on 100% of these reports. This is done due to the fact that each reported incidents is investigated and a complete analysis/patient-safety-work-product report is generated by radiation oncology domain-experts. Conclusions Because of the completeness of the data, the system has enabled us to analyze process steps and track trends of major errors which in the future will lead to implementing system wide process improvement steps and safe standard operating procedures for each radiotherapy treatment modality/technique and fulfills our goal of “Effecting Quality While Treating Safely”. RIRAS developed and copyrighted by TSG Innovations Inc.

60 APPLIED LIFE SCIENCES↗

SU-E-T-511: Inter-Rater Variability in Classification of Incidents in a New Incident Reporting System

Purpose To determine how consistent the results of different raters are when reviewing the same cases within the Radiation Oncology Incident Learning System (ROILS). Methods Three second-year medical physics graduate students filled out incident reports in spreadsheets set up to mimic ROILS. All students studied the same 33 cases and independently entered their assessments, for a total of 99 reviewed cases. The narratives for these cases were obtained from a published International Commission on Radiological Protection (ICRP) report which included shorter narratives selected from the Radiation Oncology Safety Information System (ROSIS) database. Each category of questions was reviewed to see how consistent the results were by utilizing free-marginal multirater kappa analysis. The percentage of cases where all raters shared full agreement or full disagreement was recorded to show which questions were answered consistently by multiple raters for a given case. The consistency among the raters was analyzed between ICRP and ROSIS cases to see if either group led to more reliable results. Results The categories where all raters agreed 100 percent in their choices were the event type (93.94 percent of cases 0.946 kappa) and the likelihood of the event being harmful to the patient (42.42 percent of cases 0.409 kappa). The categories where all raters disagreed 100 percent in their choices were the dosimetric severity scale (39.39 percent of cases 0.139 kappa) and the potential future toxicity (48.48 percent of cases 0.205 kappa). ROSIS had more cases where all raters disagreed than ICRP (23.06 percent of cases compared to 15.58 percent, respectively). Conclusion Despite reviewing the same cases, the results among the three raters was widespread. ROSIS narratives were shorter than ICRP, which suggests that longer narratives lead to more consistent results. This study shows that the incident reporting system can be optimized to yield more consistent results.

60 APPLIED LIFE SCIENCES↗

TU-CD-BRD-02: Henry Ford Hospital System Experience, with Focus On Motivating and Reviewing

It has long been standard practice in radiation oncology to report internally when a patient’s treatment has not gone as planned and to report events to regulatory agencies when legally required. Most potential errors are caught early and never affect the patient. Quality assurance steps routinely prevent errors from reaching the patient, and these “near misses” are much more frequent than treatment errors. A growing number of radiation oncology facilities have implemented incident learning systems to report and analyze both errors and near misses. Using the term “incident learning” instead of “event reporting” emphasizes the need to use these experiences to change the practice and make future errors less likely and promote an educational, non-punitive environment. There are challenges in making such a system practical and effective. Speakers from institutions of different sizes and practice environments will share their experiences on how to make such a system work and what benefits their clinics have accrued. Questions that will be addressed include: How to create a system that is easy for front line staff to access How to motivate staff to report How to promote the system as positive and educational and not punitive or demeaning How to organize the team for reviewing and responding to reports How to prioritize which reports to discuss in depth How not to dismiss the rest How to identify underlying causes How to design corrective actions and implement change How to develop useful statistics and analysis tools How to coordinate a departmental system with a larger risk management system How to do this without a dedicated quality manager Some speakers’ experience is with in-house systems and some will share experience with the AAPM/ASTRO national Radiation Oncology Incident Learning System (RO-ILS). Reports intended to be of value nationally need to be comprehensible to outsiders; examples of useful reports will be shown. There will be ample time set aside for audience members to contribute to the discussion. Learning Objectives: Learn how to promote the use of an incident learning system in a clinic. Learn how to convert “event reporting” into “incident learning”. See examples of practice changes that have come out of learning systems. Learn how the RO-ILS system can be used as a primary internal learning system. Learn how to create succinct, meaningful reports useful to outside readers. Gary Ezzell chairs the AAPM committee overseeing RO-ILS and has received an honorarium from ASTRO for working on the committee reviewing RO-ILS reports. Derek Brown is a director of http://TreatSafely.org . Brett Miller has previously received travel expenses and an honorarium from Varian. Phillip Beron has nothing to report.

60 APPLIED LIFE SCIENCES↗

WE-B-Exhibit Hall-01: Ask the RO-ILS Experts

Have a question about RO-ILS: Radiation Oncology Incident Learning System™, or interested in learning more? Sponsored by the American Society for Radiation Oncology (ASTRO) and AAPM, RO-ILS is the only medical specialty society-sponsored incident learning system for radiation oncology. It facilitates safer and higher quality care in radiation oncology by providing a mechanism for shared learning in a secure and non-punitive environment. Please join our RO-ILS experts for a question and answer session on Wednesday, July 15th at 8:30 in the Partners in Solutions Room in Exhibit Hall C. Our experts include: Gary Ezzell, PhD, Mayo Clinic Arizona, [Brett Miller, Phillip Beron, and Derek Brown], Emily Sanscrainte from Clarity PSO and Cindy Tomlinson, MPP, ASTRO.

60 APPLIED LIFE SCIENCES↗

WE-G-BRA-01: Patient Safety and Treatment Quality Improvement Through Incident Learning: Experience of a Non-Academic Proton Therapy Center

Purpose: Incident learning has been proven to improve patient safety and treatment quality in conventional radiation therapy. However, its application in proton therapy has not been reported yet to our knowledge. In this study, we report our experience in developing and implementation of an in-house incident learning system. Methods: An incident learning system was developed based on published principles and tailored for our clinical practice and available resource about 18 months ago. The system includes four layers of error detection and report: 1) dosimetry peer review; 2) physicist plan quality assurance (QA); 3) treatment delivery issue on call and record; and 4) other incident report. The first two layers of QA and report were mandatory for each treatment plan through easy-to-use spreadsheets that are only accessible by the dosimetry and physicist departments. The treatment delivery issues were recorded case by case by the on call physicist. All other incidents were reported through an online incident report system, which can be anonymous. The incident report includes near misses on planning and delivery, process deviation, machine issues, work flow and documentation. Periodic incident reviews were performed. Results: In total, about 116 errors were reported through dosimetry review, 137 errors through plan QA, 83 treatment issues through physics on call record, and 30 through the online incident report. Only 8 incidents (2.2%) were considered to have a clinical impact to patients, and the rest of errors were either detected before reaching patients or had negligible dosimetric impact (<5% dose variance). Personnel training & process improvements were implemented upon periodic incident review. Conclusion: An incident learning system can be helpful in personnel training, error reduction, and patient safety and treatment quality improvement. The system needs to be catered for each clinic’s practice and available resources. Incident and knowledge sharing among proton centers are encouraged.

60 APPLIED LIFE SCIENCES↗

WE-G-BRA-03: Developing a Culture of Patient Safety Utilizing the National Radiation Oncology Incident Learning System (ROILS)

Purpose: To transition from an in-house incident reporting system to a ROILS standards system with the intent to develop a safety focused culture in the Department and enroll in ROILS. Methods: Since the AAPM Safety Summit (2010) several safety and reporting systems have been implemented within the Department. Specific checklists and SBAR reporting systems were introduced. However, the active learning component was lost due to reporting being viewed with distrust and possible retribution.To Facilitate introducing ROILS each leader in the Department received a copy of the ROILS participation guide. Four specific tasks were assigned to each leader: develop a reporting tree, begin the ROILS based system, facilitate adopting ROILS Terminology, and educate the staff on expectations of safety culture. Next, the ROILS questions were broken down into area specific questions (10–15) per departmental area. Excel spreadsheets were developed for each area and setup for error reporting entries. The Role of the Process Improvement Committee (PI) has been modified to review and make recommendations based on the ROILS entries. Results: The ROILS based Reporting has been in place for 4 months. To date 64 reports have been entered. Since the adoption of ROILS the reporting of incidents has increased from 2/month to 18/month on average. Three reports had a dosimetric effect on the patient (<5%) dose variance. The large majority of entries have been Characterized as Processes not followed or not sure how to Characterize, and Human Behavior. Conclusion: The majority of errors are typo’s that create confusion. The introduction of the ROILS standards has provided a platform for making changes to policies that increase patient safety. The goal is to develop a culture that sees reporting at a national level as a safe and effective way to improve our safety, and to dynamically learn from other institutions reporting.

60 APPLIED LIFE SCIENCES↗

SU-F-E-16: A Specific Training Package for Medical Physicists in Support to Nuclear and Radiological Emergency Situations

Purpose: To provide the professional medical physicists with adequate competencies and skills in order to help them get prepared to support Nuclear or Radiological Emergency (NRE) situations. Methods: Although clinical medical physicists working have in-depth knowledge in radiation dosimetry, including dose reconstruction and dose measurements, they are usually not involved in NRE situations. However, in a few instances where medical physicists were involved in NREs, it appeared that many lacked specific knowledge and skills that are required in such situations. This lack of specific knowledge and skills is probably due to the fact that most current medical physics curricula do not include a specific module on this topic. As a response to this finding, the IAEA decided to initiate a project to develop a specific training package to help prepare medical physicists to support NRE situations. The training package was developed with the kind support of the Government of Japan and in collaboration with Fukushima Medical University (FMU) and the National Institute of Radiological Sciences (NIRS). Results: The first International Workshop to test the training package was held in Fukushima, Japan in June 2015. It consisted of lectures, demonstrations, simulation, role play, and practical sessions followed by discussions. The training was delivered through 14 modules which were prepared with the support of 12 lecturers. A knowledge assessment test was done before the workshop, followed by the same test done at the end of the Workshop, to assess the knowledge acquired during the training. Conclusion: The Workshop was successfully implemented. The overall rating of the workshop by the participants was excellent and all participants reported that they acquired a good understanding of the main issues that are relevant to medical physics support in case of NRE situations. They are expected to disseminate the knowledge to other medical physicists in their countries.

07 ISOTOPE AND RADIATION SOURCES↗