Hong Kong West Cluster Document No. [Document No.

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Policy and processes on safe handling of Review Date [Review Date(DMS)]

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Policy and processes on safe handling of radioactive substances and compliance to Radiation
Ordinance

Version Effective Date

1.0 [Effective Date(DMS)]

Document Number [Document No.(DMS)]

Author [Document Author(DMS)]
Custodian [Custodian(DMS)]
Approved By [Approving Body(DMS)]
Approver [Approved By(DMS)] (Signed)
Distribution List HKWC Radioactive Substances User Depts

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PURPOSE
This document outlines the processes for safe and proper handling of radioactive substances while
ensuring compliance with statutory requirements. Departments and Units handling radioactive
materials must familiarize themselves with relevant laws, regulations and guidelines governing the
purchase, use, storage, and disposal of such materials. Compliance is essential to prevent legal
consequences and ensure operational safety.

SCOPE
These processes apply to all personnel involved in the handling of radioactive substances or
specimens in Hong Kong West Cluster (hereafter as the “HKWC”).

LICENSING AND PERMITTING

The use of Radioactive Substances is governed by Hong Kong Ordinance Cap 303 and Cap 303a.
Before handling radioactive substances, Departments/Units must obtain the necessary licenses from
the Radiation Board. Licenses authorize the specific activities involving radioactive materials and
outline the conditions and restrictions for their use. It is crucial to maintain up-to-date licenses and
promptly renew them to avoid any interruptions in operations.

DEFINITIONS
 Radioactive substance: refers to any substance which consists of or contains any radioactive
chemical element whether natural or artificial and whose specific activity exceeds 75 Bq of
parent radioactive chemical element per gram of substances.
 Sealed source means a radioactive substance which is permanently enclosed in a container in
such a manner that it or any part of it cannot be separated from the container unless the
container is damaged, but also in such a manner as to permit the emission of radiation.
 Unsealed sources are radioactive materials that are not encapsulated or fixed in a solid form,
such as liquids, gases, or powders. They can be easily dispersed, spilled, or transferred during
handling or processing.
 Radioactive specimen: Any biological sample containing radioactive material, such as blood,
tissue, or urine.
 Radioactive waste: Any waste material contaminated with radioactive substances.
 Classified Radiation Workers (CRW) are personnels who work with Unsealed Radioactive
Substances and/or the annual radiation dose received may be greater than or equal to 3/10 of the
annual dose limit of 20 mSv.

RESPONSIBILITIES OF PERSONNEL IN THE DEPARTMENT

 Chief of Service (COS): Responsible for radiation safety of staff, patients and members of the
public (if applicable) in the Department. Appoint suitable Radiation Protection Supervisors
(RPS). Report to Hospital Chief Executive (HCE) on incidents involving over-exposure, new

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radiation work, change of the nature of radiation work and other matters which may affect
radiation safety of the Department.
 Division Heads and Department Managers: Responsible for the implementation and adherence
to a Radiation Safety Program, and ensures the safety of personnel working with radioactive
materials.
 Radiation Protection Supervisor (RPS): Responsible for overseeing the department’s/unit’s
radiation safety program and ensuring compliance with all applicable regulations. Provides
radiation safety training and guidance to personnel, conducts radiation surveys, and monitors
personnel exposure to radiation.
 Radiation Protection Advisor (RPA): Overseeing radiation safety, supporting end-users,
monitoring compliance with the radiation ordinance, advising CCE, HCEs, and COSs/Heads of
Units on radiation protection and compliance, and conducting investigations on incidents of
over-exposure and other radiation safety matters as requested.

NEW PROCEDURES / PRACTICES INVOLVING RADIOACTIVE SUBSTANCES

1. Carry out risk assessments before undertaking any activity involving work with radioactive
substances and prepare contingency plans to deal with foreseeable adverse incidents.
2. Prepare written local rules prescribing the arrangements for controlling work with ionizing
radiations for any designated controlled areas.
3. Obtain approval from the COS or designee for new acquisition of radioactive substances not in
current use in the Department. COS should obtain approval from Hospital Chief Executive
before commencing new radiation work or changing nature of radiation work that have
radiation safety implications.
4. First purchase of radioactive substances is vetted by Cluster RPA to ensure compliance to
radiation safety ordinance.
5. Apply for licence from Radiation Board.
6. Order the radioactive material from a licensed supplier.

LOCAL RULES
Each department must develop a set of written Local Rules for safe working with radiation. Only
suitable trained personnel can be involved in radiation work.

WORKING WITH RADIOACTIVE SUBSTANCES

1. Designated areas: Works/storage involving radioactive substances can only be carried out in
locations specified in the license. All entryways to spaces permitted to use/store radioactive
materials must display a radioactive material sign. Only authorized personnel can enter such
areas.

2. Receipt of Radioactive Material:

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a) Upon receiving radioactive material, inspect the packaging for accurate labelling,
damage, or leakage.
b) Conduct wipe tests and dose survey to check for possible leaks. Immediately notify the
RPS and the supplier if any damage or leakage is detected.
c) After securely storing the radioactive material, record it in the inventory log.

3. Working with Radioactive Substances:

a) Only individuals with appropriate training are permitted to handle radioactive
materials. Individuals who work with unsealed radioactive substances and/or expected
to receive an annual dose > 6mSv will be designated as 'Classified Radiation Workers”
(CRW). They should wear personal dosimeters while at work and have body check in
every 14 months.
b) Observe ALARA (As Low As Reasonably Achievable) principle to minimize radiation
exposure.
c) Activities involving radioactive substances can only be carried out in locations
specified by the RS license.
d) All personnel working with open radioactive materials must wear personal protective
equipment (PPE), including lab coats, disposable gloves, and safety glasses.
e) No eating, drinking or smoking are allowed in controlled areas. Handle radioactive
materials with care to prevent spills or contamination.
f) Each individual radiation source (or container) shall be labelled clearly indicating the
date, radionuclide, activity and volume (if applicable).
g) Notify the RPS immediately in case of any spills or contamination incidents.
h) All amount of radioactive substances used, stored or discarded as waste must be logged
into the appropriate inventory system.
i) Any female radiation worker who are pregnant should inform the RPS immediately.
j) Pregnant staff and breastfeeding staff should not take part in any work or work in areas
where there is significant risks of body contamination.
k) Pregnant staff should not take part in any work which may result in receiving a dose of
1 mSv to the abdomen (in the gestation period).

4. Storage of Radioactive Substances:

a) RPS and custodian should ensure that any radioactive substances not in use or being
transported are kept:
i. In a suitable receptacle and
ii. In a suitable store.
b) The storage location of the radioactive material should be isolated from occupied areas
and access is restricted to authorized persons. It should be locked and monitored
routinely.

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c) All radioactive substances should be stored in suitable receptacles such that the dose
rate <10 μSv/hr in the store and <1 μSv/hr outside the store.
d) The store should be indicated by a radiation warning sign, with the name and telephone
number of the RPS.
e) If only a small number of minor sources are held, such items can be stored in a suitable
metal cabinet (dose rate near the storage cabinet < 1 μSv/hr ) within a general store.
The general store should be locked and monitored routinely. The metal cabinet should
have a radiation warning sign.

5. Transport of Radioactive Substances:

a) Packaging of radioactive materials for transport shall be secure and so designed that the
package can be easily handled.
b) Radiation warning sign with radionuclide with activity and date should be affixed on
the container of the radioactive material / specimen.
c) The sample is then double-bagged and placed in designated transport carts for
transport.

6. Waste Management and Disposal:

a) Users are responsible for disposal of radioactive wastes as described in the RS license.
b) Only radioactive materials and potentially contaminated items are disposed into the
radioactive waste container for storage until final disposal.
c) Radioactive wastes shall be packaged in closed metal containers, opaque plastic bags or
multi-layer bags.
d) Radioactive wastes should be stored for delay period specified by the RS license before
disposal as chemical waste or household waste. If wastes have other hazardous natures,
they shall be managed according to relevant requirements.
e) Survey for activity level before disposal. Level should be around background level.
f) Remove radioactivity warning label when disposed as household wastes.
g) Aqueous liquid wastes shall be disposed of at the end of the minimum delay period in 4
approximately equal portions at 7 days’ intervals. The wastes should be discharged into
designated sinks with plenty of flushing.
h) A waste management record should be maintained which contains the details of the
radionuclide, physical and chemical forms, radioactivity, dates of production and
disposal, disposal arrangements.
i) Waste store

7. Area Monitoring
a) Radiation level inside store room <10 μSv/hr. Radiation level in any accessible area
outside the store room ≤1 μSv/hr.

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b) Areas in which gamma or high-energy beta emitters have been used should be surveyed
by a radiation survey meter regularly for contamination.
c) When low-energy beta emitters are used, a combination of wipe testing and liquid
scintillation counting can be employed for area monitoring. Hong Kong University
Safety Office can provide service on liquid scintillation counting (contact:
[email protected]).

8. Operating Procedures for Radiation Survey Meters

a) Check the date of last calibration. Note that meters are required to be calibrated at least
once a year. Contact Medical Physics Unit (ext 4371) for calibration service.
b) Check batteries before use.
c) Determine the operating background. With the meter turned on and the selector at its
lowest scale, point the detector away from any radiation source and measure the
background. Normal background reading for survey meters are about 0.2 μSv/hr, or 20-
40 cpm for Geiger meters.
d) With the speaker on, point the probe window at the area you wish to monitor for
radiation exposure or radioactive contamination. Move the probe slowly and if
measured level is greater than or equal to 3 times the background, radioactivity may
present and needs further action.

9. Emergency Procedures:
 In event of a spill or an emergency involving radioactive material, the immediate objectives
are to:
i. Render first aid, if necessary.
ii. Prevent or reduce the chance of personal contamination.
iii. Prevent dispersal of the contaminant.
iv. Begin personal decontamination, if necessary.
v. Decontaminate the area under the supervision of RPA or Physicist
vi. Document all spills or contamination incidents and the corrective actions taken.
 Refer to flowchart in Appendix A.

 Minor Spill:
Spill volume manageable and poses no immediate danger to personnel.
i. Notify all individuals in the room at once.
ii. If spill on person, apply personal decontamination immediately.
iii. Limit access to the area to those necessary to deal with the spill.
iv. Confine the spill.
v. Contact duty physicists and notify RPS of the spill at first opportunity.
vi. Survey personnel involved with the spill before they disperse. Decontaminate or
change clothes if necessary.
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vii. Complete systematic decontamination based on a pre-established plan of action.

viii. Consider notifying/consulting the hospital Radiation Protection Advisor. Report to
COS, Division Head and Department Manager as appropriate.

 Major Spill and Emergencies:

Major spill are spills involving mCi or greater activity, or when personal injury or fire are
involved. These situations require additional assistance:
i. Notify all individuals in the room at once.
ii. If on fire, activate fire alarm. Dial “4444”/”999” to report fire.
iii. If an individual is injured, apply immediate first aid as necessary.
iv. If spill on person, apply personal decontamination immediately.
v. During working hours, notify RPA (ext: 1035). During holidays, evenings, and
weekends, contact duty physicists (Jerry Cheung 9167 7556, Heidi Lui 6280 0609,
Kay Chung 6937 8884).
vi. Remove personnel from the area of the spill and hold them nearby until they can be
checked for contamination by physicists.
vii. Seal the room avoiding additional contamination of personnel.
viii. Decontaminate the area following a pre-established plan.
ix. Monitor all personnel involved in a spill and cleanup.
x. Report to RPA, COS, Division Head and Department Manager as appropriate.

ACCOUNTING FOR RADIOACTIVE SUBSTANCES

 An appropriate accounting procedure should be set up to ensure the locations of all radioactive
sources are always known. All accountable sealed radioactive sources should be inventoried at
intervals not to exceed 6 months.
 Regular wipe tests / leakage tests is required for sealed radioactive sources. Leakage tests
should be conducted by qualified persons. Contact Medical Physics Unit (ext 4371) for leakage
test service.

INCIDENCE HANDLING AND REPORTING

 Any loss or theft of radioactive source, or when radioactive sources on the inventory cannot be
accounted for, the user should notify the RPS who in turn should notify the Management. The
Management is advised to report the incident immediately to the police and the Radiation
Board. If the report to Radiation Board is made verbally, it should be followed by a report in
writing made within 48 hours.
 For reporting of all radiation incidences, refer to flow chart in Appendix B.
 If incidence involves violation of radiation ordinance, the Radiation Board should be informed.
 The incidence should also be reported to HAHO AH/BSSD Chief Manager by reporting in the
HA RSC Meeting.

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DOCUMENTATION
 Records of acquisition: Maintain records of all radioactive substances or specimens acquired,
including supplier information, procurement dates.
 Records of storage: Maintain records of all radioactive substances in storage.
 Exposure records: Document personnel exposure to radiation, including dosimeter readings and
any incidents involving potential exposure.
 Waste disposal records: Maintain records of radioactive waste disposal, including waste storage,
disposal dates, waste characterization information, and disposal methods.
 Document all spills or contamination incidents and the corrective actions taken.
 Training records.

RESOURCES
For further information, please refer to the following resources and/or procedures:
1. Code of Practice on Radiation Safety 2022, Hospital Authority:
http://portal.home/sites/osh/manual/default.aspx
2. Radiation Ordinance: https://elegislation.gov.hk/hk/cap303
3. Radiation Ordinance: https://www.elegislation.gov.hk/hk/cap303A
4. Radiation Board of Hong Kong: https://www.rbhk.org.hk/eng/index.html
5. Radiation Health Series No. 5 Code of Practice for the Management of Low Level Radioactive
Wastes and Disused Sources: https://www.rhd.gov.hk/en/pdf/Pub5_english.pdf
6. Radiation Health Series No. 6 Ionizing Radiation:
https://www.rhd.gov.hk/en/pdf/Pub6_english.pdf
7. Guidance Notes on the Storage and Accounting for Radioactive Sources:
https://www.rhd.gov.hk/en/pdf/guidance_rs_storage_english.pdf
8. IAEA Specific Safety Guide No. SSG - 46- Radiation Protection and Safety in Medical Uses
of Ionizing Radiation: https://www-pub.iaea.org/MTCD/Publications/PDF/PUB1775_web.pdf
9. IAEA Safety Reports Series No. 40 – Applying Radiation Safety Standards in Nuclear
Medicine: https://www-pub.iaea.org/MTCD/Publications/PDF/PUB1775_web.pdf

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APPENDIX A: FLOW CHART OF HANDLING SPILL OF RADIOACTIVE SUBSTANCES

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APPENDIX B: INCIDENCE REPORTING

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