Radiation Safety Officer 101

While being an essential part of the functioning of a medical facility, we often find that clients and prospective clients lack a true understanding of the scope, responsibilities and best practices related to the position of Radiation Safety Officer (RSO) in a medical facility.

Equally as important, when lapses occur in radiation safety at medical facilities (which they sometimes do), it is important that a competent and engaged RSO is there to help protect patients and staff from harm, and the facility from regulatory scrutiny and liability. Fines of $100,000 and up have been levied against medical facilities for failures in radiation safety and lawsuits can have a devastating effect on the business and morale of a medical facility.

A radiation safety program at a medical facility led by an RSO is governed by hundreds of regulatory requirements in federal and state regulations, but we undertake in this article the goal of articulating the essence of those disparate regulations and requirements in an easier to read form.

This article will address two key pieces to the RSO puzzle:

1. Radiation Safety Officer 101

What are the basics of the RSO position, including scope, competency requirements and responsibilities of the RSO?
2. The Six Habits of a Highly Effective RSO

What are some observed best practices of RSOs within medical facilities?

So, let’s start with the most basic questions we hear related to radiation safety officers within medical facilities.

PART 1: RADIATION SAFETY OFFICER 101

Question 1: Am I required to have an RSO at my medical facility?

In basic terms, medical facilities are required to obtain a license when “intentionally administering byproduct material, or radiation from byproduct material” (i.e. administering radioactive materials) to patients or human research subjects. This would generally be facilities using radioactive materials for treatment or diagnostic purposes. Under these licenses, a radiation safety officer is required.

Question 2: What are the regulations that govern RSOs and radiation safety programs?

There are numerous U.S. Nuclear Regulatory Commission (NRC) regulations governing radiation safety, licenses and medical use of radioactive materials (See 10 CFR 19, 10 CFR 20 and 10 CFR 35), in addition to separate state or other governing body regulations (e.g. VHA/NHPP) all covering the scope, duties and responsibilities of the RSO in a medical facility. Other guidance documents, like NUREG 1556. Vol 9, offer additional guidance on materials licenses for medical use.

Question 3: What role does the RSO play in the administration of radioactive materials to patients in a medical facility?

Under NRC regulations, administrations of radioactive materials must be conducted by an “authorized user.” By definition, an “authorized user” is a physician, dentist or podiatrist who meets certain training and experience requirements of the NRC or an Agreement State license, which is most often a board certification. Generally, the RSO plays a key role in ensuring that only an “authorized user” is administering radioactive materials. If the RSO is an “authorized user,” then they may also directly administer radioactive materials to patients.

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About the author

Keith Burns

Keith Burns is the President of Krueger-Gilbert Health Physics, Inc., where he directs the company's strategy, operations, finance and administration. Mr. Burns is also the co-managing partner and director of Seneca Creek Partners LLC, a private investment fund. Prior to founding Seneca Creek, he was in the Compliance Department at Goldman, Sachs & Co. where he covered the Principal Funding & Investing, Structured Credit, Short-Term Interest Rates and Third-Party Distribution businesses and led the implementation of key Dodd-Frank risk management initiatives. Mr. Burns also has several years of experience as a corporate attorney with Jones Day and Latham & Watkins LLP, where he led numerous deal teams, and structured and negotiated over $1 billion of private equity acquisitions and financings.