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Extra info for Accidental Overexposure of Radiotherapy Patients in San Jose, Costa Rica

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WRITTEN PROCEDURES The working procedures for normal conditions were not available. The emergency procedures were not able to be viewed at the time of the Expert Team’s assessment. 7. 1. Status of the charts A total of 113 patient therapy charts were reviewed, of which nine were from the Children’s Hospital, 37 from the Calderón Guardia Hospital and the remaining 67 from the San Juan de Dios Hospital. The therapy charts were reviewed at the San Juan de Dios Hospital and at the law courts. None of those persons in charge at the time of the accident, including the dosimetrist, the radiation therapist from the San Juan de Dios Hospital and the person who performed the initial calculation and calibration, were available for an interview in an effort to reconstruct the charts.

It then emerged that, instead of 18 s, a value of 30 s seems to have been used to determine the dose rate. 66. As a result, the dose rate would have been underestimated by the same factor, and therefore the dose to patients would consequently have been higher than that intended. 4. REGULATORY ACTIONS On 3 October 1996, the person in charge of dosimetry at the San Juan de Dios Hospital contacted the Section for Control of Ionizing Radiation of the Ministry of Health of Costa Rica, which is responsible for monitoring compliance with the regulations on radiation protection.

1. REQUEST TO THE IAEA TO UNDERTAKE AN EXPERT ASSESSMENT On 16 October 1996, the President of the Comisión de Energía Atómica de Costa Rica (CEA) (Atomic Energy Commission of Costa Rica), who is Adviser to the Resident Representative of Costa Rica to the IAEA and normally the Costa Rican technical counterpart for the Agency, officially informed the IAEA of the accident and requested “the support and collaboration of the IAEA as a matter of urgency, in order to do whatever was appropriate”. In doing so, he relayed a request to the CEA by the then Co-ordinator of an “ad hoc group for the administrative process” established by the CCSS.

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