Certification by the American board of medical physics in radiation oncology physics.
A master's or doctor's degree in physics, biophysics, radiological physics or health physics and have completed one year of full-time training in therapeutic radiological physics and one year of full-time work experience under the supervision of a medical physicist at a medical institution. A person qualifying under this subdivision shall work under the supervision of a medical physicist qualified under subd. 1.
A registrant employing a physicist who qualifies under this subdivision shall provide the department with a statement of training and experience, signed by the preceptor medical physicist or provide a letter from another state accepting the person as a therapeutic medical physicist.
The medical physicist shall be responsible for all of the following:
Beam data acquisition and transfer for computerized dosimetry and supervision of its use.
Consultation with the physician user in treatment planning, as needed.
Performance of calculations and assessments regarding medical events.
Acceptance testing of the machine after any repair or service that may have altered the machine's performance characteristics.
If the medical physicist is not a full-time employee of the registrant, the operating procedures shall also specifically address how the medical physicist is to be contacted for problems or emergencies, as well as the specific actions to be taken until the medical physicist may be contacted.
A person who will be operating a therapeutic radiation machine for medical use shall be an American registry of radiologic technologists registered radiation therapy technologist or a user authorized under sub. (2)
. A person who is not an ARRT registered radiation therapy technologist shall submit evidence that he or she has satisfactorily completed a radiation therapy technologist training program that complies with the requirements of the joint review committee on education in radiologic technology.
DHS 157.82 Note
"Essentials and Guidelines of an Accredited Educational Program for the Radiation Therapy Technologist", Joint Review Committee on Education in Radiologic Technology, 1988, establishes the requirements for a therapy technologist training program. The document is available at: http://www.jrcert.org/
The names and training of all personnel currently authorized to operate a therapeutic radiation machine shall be kept on file at the facility. Information on former operators shall be retained for a period of at least 3 years beyond the last date they were authorized to operate a therapeutic radiation machine at that facility.
A person who will be operating an electronic brachytherapy unit shall complete device specific instruction from the manufacturer or individual trained by the manufacturer, and training on procedures required by s. DHS 157.85 (16) (g) 4.
(6) Safety procedures.
Written safety procedures and rules, including any restrictions required for the safe operation of the particular therapeutic radiation machine, shall be developed by a medical physicist and shall be available in the control area of a therapeutic radiation machine. The operator shall be able to demonstrate familiarity with these rules.
(7) Written directive required.
Persons may not be exposed to the useful beam except for medical therapy purposes and unless exposure has been ordered in writing by a physician user qualified under sub. (2)
. This provision specifically prohibits deliberate exposure of an person for training, demonstration or other non-healing arts purposes.
(8) Information and records.
The registrant shall maintain all of the following information in a separate file or package for each therapeutic radiation machine for inspection by the department:
Records of all surveys, calibrations and periodic quality control checks of the therapeutic radiation machine, as well as the names of persons who performed those activities.
Records of maintenance or modifications performed on the therapeutic radiation machines, as well as the names of persons who performed these services.
Signature of each person authorizing the return of a therapeutic radiation machine to clinical use after service, repair or upgrade.
(9) Record retention.
All records required by sub. (8)
shall be retained for 3 years or until disposal is authorized by the department. Any required record generated prior to the last department inspection may be microfilmed or otherwise archived as long as a complete legible copy of the record may be retrieved.
DHS 157.82 History
History: CR 01-108
: cr. Register July 2002 No. 559
, eff. 8-1-02; CR 09-062
: cr. (2) (c) and (5) (c), am. (6) Register April 2010 No. 652
, eff. 5-1-10.
Administrative policies and procedures for radiation therapy machines. DHS 157.83(1)
A registrant shall have written policies and procedures to ensure that radiation will be administered as directed by an authorized user. The policies shall meet all of the following specific objectives:
Prior to administration, a written directive is prepared for any external beam radiation therapy dose or electronic brachytherapy dose. A written revision to an existing written directive may be made prior to beginning treatment, or prior to delivery of a fractional dose, provided that the revision is dated and signed by an authorized user. If, because of the patient's condition, a delay to provide a written revision to an existing written directive would jeopardize the patient's health, an oral revision to an existing written directive shall be acceptable provided that the oral revision is documented immediately in the patient's record and a revised written directive is signed by an authorized user within 24 hours of the oral revision.
Prior to the administration of each course of radiation treatments, the patient's identity is verified, by more than one method, as the person named in the written directive.
External beam radiation therapy or electronic brachytherapy final plans of treatment and related calculations are according to the respective written directives.
Any unintended deviation from the written directive is identified, documented, evaluated and appropriate action is taken.
(2) Development of the operational procedures program.
A therapy device registrant shall do all the following:
Develop an operational procedures program that specifies staff duties and responsibilities, and equipment and procedures. The registrant shall implement the program upon issuance of a certificate of registration by the department.
Develop procedures for and conduct a review of the program including, since the last review, an evaluation of a representative sample of patient administrations and all medical events to verify compliance with all aspects of the operational procedures program.
Conduct program reviews at intervals not to exceed 12 months.
Evaluate each of the reviews specified in par. (b)
to determine the effectiveness of the program and, if required, make modifications to meet the requirements of par. (b)
Maintain records of each review specified in par. (b)
, including the evaluations and findings of the review, in an auditable form for 3 years.
A registrant shall report any of the following medical events:
A dose that differs from the prescribed dose by more than 0.05 Sv (5 rem) effective dose equivalent, 0.5 Sv (50 rem) to an organ or tissue or 0.5 Sv (50 rem) shallow dose equivalent to the skin and any of the following exist:
The fractionated dose delivered exceeds the prescribed dose, for a single fraction, by 50% or more.
A dose that exceeds 0.05 Sv (5 rem) effective dose equivalent, 0.5 Sv (50 rem) to an organ or tissue or 0.5 Sv (50 rem) shallow dose equivalent to the skin under any of the following conditions:
A dose to an organ outside the intended treatment volume that exceeds the expected dose to that organ by 0.5 Sv (50 rem) where the excess dose is greater than 50% of the expected dose to that organ.
In response to a medical event, a registrant shall do all of the following:
Notify their department head no later than the next calendar day after discovery of the medical event.
Submit a written report to the department within 15 working days after discovery of the medical event. The written report shall include: the registrant's name; the prescribing physician's name; a brief description of the event; the effect on the patient; what improvements are needed to prevent recurrence; actions taken to prevent recurrence; whether the registrant notified the patient or the patient's responsible relative or guardian and if not, why not; and if the patient was notified, what information was provided to the patient.
DHS 157.83 Note
Note: Mail the report to the Department at: Department of Health Services, Radiation Protection Section, PO Box 2659, Madison WI 53701-2659.
The report in subd. 2. a.
may not include the patient's name or other information that could lead to identification of the patient.
Notify the referring physician and the patient of the medical event no later than 24 hours after the medical event's discovery, unless the referring physician personally informs the registrant either that he or she will inform the patient or that, based on medical judgment, telling the patient would be harmful. The registrant is not required to notify the patient without first consulting the referring physician. If the referring physician or patient cannot be reached within 24 hours, the registrant shall notify the patient of the medical event as soon as possible. The registrant may not delay any appropriate medical care for the patient, including any necessary remedial care as a result of the medical event, because of any delay in notification.
Retain a record of each medical event for 3 years. The record shall contain all of the following:
A brief description of the event, why it occurred and the effect on the patient.
What improvements are needed to prevent recurrence and the actions taken to prevent recurrence.
Whether the registrant notified the patient or patient's guardian and if not, why not, and if the patient was notified, what information was provided to the patient.
If information was not given to the patient at the direction of the referring physician, the reason why the information was not given to the patient.
If the patient was notified, furnish, within 15 working days after discovery of the medical event, a written report to the patient by sending either a copy of the report that was submitted to the department, or a brief description of both the event and the consequences as they may affect the patient, if a statement is included that the report submitted to the department may be obtained from the registrant.
Aside from the notification requirement, nothing in this section affects any rights or duties of registrants and physicians in relation to each other, patients or the patient's responsible relatives or guardians.
DHS 157.83 History
History: CR 01-108
: cr. Register July 2002 No. 559
, eff. 8-1-02; CR 06-021
: am. (2) (b) Register October 2006 No. 610
, eff. 11-1-06; CR 09-062
: am. (1) (a) and (c) Register April 2010 No. 652
, eff. 5-1-10.
Technical requirements for facilities using therapeutic radiation machines. DHS 157.84(1)(a)(a)
A registrant shall ensure that radiation protection surveys of all new facilities and existing facilities not previously surveyed are performed with an operable, calibrated survey instrument. The radiation protection survey shall be performed by or under the direction of a medical physicist and shall verify that, with the therapeutic radiation machine in a "BEAM-ON" condition, with the largest clinically available treatment field and with a scattering phantom in the useful beam of radiation, all of the following requirements are met:
A radiation protection survey shall be performed prior to any subsequent medical use after making any of the following changes:
Any change in the location of the therapeutic radiation machine within the treatment room.
Using the therapeutic radiation machine in a manner that could result in increased radiation levels in areas outside the external beam radiation therapy treatment room.
Instances where the facility, in the opinion of the medical physicist, is in violation of applicable regulations.
The instruments used to measure radiation levels and their last date of calibration.
A floor plan of the areas surrounding the treatment room that were surveyed.
The radiation level at several points in each area expressed in microsieverts or millirems per hour.
The calculated maximum level of radiation over a period of one week for each restricted and unrestricted area.