Q: Can you have multiple operators performing elements of one defined task but only one of them taking responsibility?
A: Where several staff are involved in a particular task, the employer must define in written procedures whether they all have equal legal responsibility or whether one person is acting as the responsible operator for the purpose. This decision should be taken based on local conditions, including:
Where multiple people share responsibility, it must be made clear that they are all equally and fully responsible. Alternatively, specific aspects of the process may be defined and responsibilities assigned individually.
Whichever approach is adopted, it must be clearly defined in a written procedure and there should be a description of how the operator(s) indicate they were the responsible duty holder(s).
If it is the responsibility of one operator, define which signature column(s) they complete if there are two on a treatment sheet:
Phrases such as ‘the radiographers are responsible for’ should be avoided as this does not define which duty holder is responsible.
Q: Is it necessary to define what is meant when using the term ‘checking’?
A: When using the word ‘check’ in a written procedure, it needs to be expanded to define exactly what is meant and what an individual is required to do and what responsibility they have. Equally, this will define what responsibility other individuals have taken throughout the process. The employer should seek to place responsibility appropriately and not ask individuals to check things they are not trained to check or for which they do not have the necessary data or equipment to check.
The written procedure should define whether the duty holder is expected to:
When checking something is correct, you should always seek to find ways to carry out a process in a different way to maximise the chance of identifying an error. Normally, the first person carrying out a task is more likely to do it correctly than a second person is likely to pick up an error during checking. Calculations can be checked by carrying out the calculation in a different way.
In the employer’s IR(ME)R procedures it is, however, important to identify who has the responsibility to ensure that a particular check has been carried out before an examination or treatment. The written procedures should define a series of checks that need to be carried out before examination or treatment is initiated. If the operator who initiates the exposure does so without evidence of a check being completed, they will be held responsible if it has not been. Operators are inevitably under time pressure and it is not reasonable to expect them to look through a number of different documents at this time. Systems should be in place to ensure that patients do not arrive for an examination or treatment when the checking of their data is not complete.
However, such systems can fail and it is recommended that there is a very clear indication that all the checks have been carried out. If such a system is in place and there is a clear flag showing that checks are complete, the operating radiographer should be expected to check that the flag is set. However, documentation should make it clear that the setting of the flag is not part of the operating radiographer’s duties.
Q: Can Physicians Associates refer patients for imaging if they write on the referral that the Consultant has approved it?
A: Anyone acting as the named IR(ME)R Referrer must be a registered healthcare professional.Physician Associates (PA) are (presently) not registered professionals and therefore legally cannot act as the Referrer.
The person who signs must be entitled by the IR(ME)R Employer to request clinical images using ionising radiations. The electronic signature cannot be that of the PA.
The recently published joint professional body guidance on IR(ME)R 2017 is freely available for download at https://www.rcr.ac.uk/publication/irmer-implications-diagnostic-imaging-interventional-radiology-diagnostic-nuclear-medicine with a chapter about “Duty Holders” (including Referrers).
Q: We have students and apprentice trainees in our department, can we entitle them as Operators? How much training do they need to be entitled and can they ever work unsupervised?
A: Please refer to comprehensive guidance:
Q: Our radiographers often struggle to ensure people are wearing adequate PPE in theatres, especially lead aprons. How can we support them and meet the requirements of IRR2017?
A: With regard to the Ionising Radiations Regulations 2017 (IRR), you must by law have at least one radiation protection supervisor (RPS) and a radiation protection advisor (RPA) whose duty it is to advise your Employer of issues relating to radiation protection. We would advise you to make sure both are aware of any problems with compliance. The name of your RPS can be found in your local rules.
Your Employer has responsibility under IRR 17 https://www.legislation.gov.uk/uksi/2017/1075/regulation/9/made (regulation 9 Restriction of exposure) to take all necessary steps to restrict the extent to which employees and other persons are exposed to ionising radiations. This is done using a framework of measures which include engineering, procedural and personal controls. The two aspects we are often asked about are procedural and personal controls.
Procedural controls for radiation protection of staff are usually addressed through your local rules. Local rules identify the working instructions intended to restrict exposure. It is the role of the RPS to ensure the employers procedures are adhered to, in particular in relation to the local rules. Local rules also exist to protect individuals from the biological hazards of ionising radiation and so include dose limits and a specified dose investigation level.
Your Employer will also have undertaken personal risk assessments for anyone working with ionising radiation in order to identify measures required to restrict exposure to that person. This will include estimated radiation dose rates, whether they need to be designated as classified workers etc. Complying with dose limits is a requirement. Dose limits and further helfpul information can be found in the Approved Code of Practice and guidance (ACoP or L121) document. Personal protective equipment (PPE) is one way of restricting dose but other measures such as not using ionising radiation during the procedure or maintaining a greater distance from the source/X-ray beam (e.g.standing outside the room or behind a lead, concrete, barium plastered shield) may also be considered.
Non-compliance always raises the issue of training and this is where personal controls may come in. Has the employee received adequate training for the task they are undertaking? Are they working within their entitled scope of practice? Have they signed and agreed competencies and training records? Do they understand their responsibilities under the regulations and the consequences of not complying? If not why not? For repeated non-compliance has the matter been raised with the individuals line manager? Regulation 35 of IRR 17 covers the duties of employees. This includes making full and proper use of personal protective equipment where provided.
You will find the Approved Code of Practice and guidance for IRR 17 an invaluable reference to help you resolve these matters. Approved guidance is not statutory but it references the regulations and if you follow the guidance you can be assured of compliance.
Thinking about IR(ME)R https://www.legislation.gov.uk/uksi/2017/1322/contents/made , it is important that everyone working in theatre where ionising radiations are used, know who the entitled IR(ME)R duty holders are for those theatre procedures and what their individual responsibilities are. All employees carrying out medical exposures as the entitled IR(ME)R Operator must be adequately trained, assessed as competent and entitled to do so by the Employer. There must be up to date training records for anyone operating an Image Intensifier, regardless of professional title (regulation 17). You may also wish to reference the joint professional body guidance for IR(ME)R
In terms of the remainder of your enquiry, the matter of radiographers required and list alterations, these are quite common issues which you will hopefully be able to resolve through effective communication. Do you have a local procedure that clearly defines a communication pathway with an escalation procedure for unexpected events? What is the nature of the agreement between imaging and theatres for the provision of services? Is everyone aware of this? Perhaps it needs revising because working practices have changed? Either way, a review of the effectiveness of existing communication pathways and a general “raising awareness of best practice” would be a useful exercise.
May I also suggest looking at the Quality Standard for Imaging to help you identify and develop any local procedures that may be missing currently. In particular take a look at CL1C2 which requires Systems in place to ensure a collaborative approach to define and deliver imaging pathways and to maintain communication both within and outwith the service.
If you haven’t yet watched our series of webinars which cover many of these matters, they are freely available here https://www.gotostage.com/channel/scormembers
Q: Does the referrer have to physically meet or examine a patient before requesting imaging with ionising or non ionising radiation?
A: There is nothing within IR(ME)R https://www.legislation.gov.uk/uksi/2017/1322/contents/made to require the patient to be physically examined. However there are other requirements, in particular, the requirement under regulation 10 (5) The referrer must supply the practitioner with sufficient medical data (such as previous diagnostic information or medical records) relevant to the exposure requested by the referrer to enable the practitioner to decide whether there is a sufficient net benefit as required by regulation 11(1)(b). If this requirement is not being met because the patient has not been examined or because further information comes to light when the Radiographer or Assistant Practitioner (AP) physically meets the patient, it is the duty of the IR(ME)R Operator to seek advice from the Referrer and Practitioner. The Practitioner must be able to justify the exposure or where the exposure is authorised under guidelines issued by the Practitioner, the clinical indications must fit within these for the exposure to be authorised.
The Employer has a duty under regulation 6.5 (a) to establish recommendations concerning referral guidelines for medical exposures, including radiation doses, and ensure that these are available to the referrer.If Referrers are regularly referring out with these guidelines it should be noted and the reason investigated.
During the COVID pandemic, a really important procedure for the radiation safety of patients is the conversation with the patient by the person who is providing the patient with adequate information prior to the exposure taking place (a requirement of IR(ME)R schedule 2). This is usually the Radiographer or AP as the final gatekeeper who must ensure the reason for the exposure remains current and relevant. If this is taking longer than usual it should be reflected in your local procedures and appointment scheduling or in your risk assessments if it is having an effect on patient care.
Q: Our RPS has left and no one has replaced them, can we continue to work without an RPS employed?
A: Every employer who has ionising radiation equipment used for medical purposes must employ an RPS and an RPA – this is under the Ionising Radiation Regulations 2017 (these became law in 2017 and rescinded IRR 1999) https://www.legislation.gov.uk/uksi/2017/1075/regulation/9/made.
These regulations stipulate that there must be at least one RPS for each “radiation area” and a radiation protection advisor (RPA) whose duty it is to advise your Employer of issues relating to radiation protection. Ensure your RPA is aware there is no RPS. The RPA would usually be consulted regarding the appointment of a suitable RPS. The name of the RPS should be current in your Local Rules.
Very useful Approved Code of Practice from the Health and Safety Executive is available here– of particular importance to this enquiry are pages 73 – 76.
You must by law have an RPS and that person must be trained to do that role.
Q: Can radiographers justify CT exposures?
A: All exposures of ionising radiations must be justified by an IR(ME)R Practitioner (regulation 10) https://www.legislation.gov.uk/uksi/2017/1322/regulation/10/made and (regulation 11 (5)) https://www.legislation.gov.uk/uksi/2017/1322/regulation/11/made . This may be a radiologist or a trained and entitled radiographer. We commonly see radiographers acting as the IR(ME)R Practitioner within their scope of practice. An example might be CT Head reporting radigraphers.
There is further practical guidance around justification and authorisation in chapter 7 of the joint professional body guidance IR(ME)R: Implications for clinical practice in diagnostic imaging, interventional radiology and diagnostic nuclear medicine https://www.rcr.ac.uk/publication/irmer-implications-diagnostic-imaging-interventional-radiology-diagnostic-nuclear-medicine .
IR(ME)R practitioners should be able to evidence adequate training relevant to their scope of practice and scope of entitlement. Our guidance document The Diagnostic Radiographer as the entitled IR(ME)R Practitioneroffers advice on what radiographer practitioner training might look like. It is for the IR(ME)R Employer to entitle healthcare professionals in this way and entitlement should be in writing.
There are alternative approaches to who justfies which exposures in CT:
We are currently planning the educational resources for the coming year. This is likely to be a mix of recorded webinars, similar to the ones we have already produced here: https://www.gotostage.com/channel/scormembers along with additional, more interactive, events.
While recorded sessions have value, being accessible at members’ convenience, we want to involve our members more through listening events where learning evolves through discussion. These are proving really popular at the moment.
We recognise the need to understand what members really want and how that might differ from the general training topics we have always covered.
From a radiation protection point of view we are looking at running sessions on Optimisation and DRLs and governance around non-medical referrers.
If you have any requests for other radiation protection learning events please email Lynda Johnson
Q: Can our radiographic assistants and assistant practitioners undertake any of the IR(ME)R procedures?
A: Under IR(ME)R 2017 (IR(ME)R NI 2018) Operators do not need to be registered healthcare professionals. However anyone undertaking any practical tasks related to exposures of ionising radiation must be adequately trained to understand their role and the limits of their responsibility, assessed as competent and entitled as Operators within your Employers procedures for a defined scope of practice.
Please read the latest professional body guidance for more information.
Please go to our policy and guidance document library
Q: I would like to get involved in reserach, where do I start?
A: Please visit our research pages here.
Q: I have recently left the NHS and am working for an agency. Am I able to report and if so does my PII cover me?
A: Anyone undertaking reporting should do so under a clearly defined governance framework and have access to the relevant policies and procedures and referral guidelines of the employer for whom you are providing clinical evaluations (reports).
We would advise you to ensure you have written copies of your scope of practice and your IR(ME)R scope of entitlement under your new employer. Before entitling you, it is for your employer to satisfy themselves that you have been adequately trained for the role you are undertaking.
Indemnity insurance considerations are very important when working out with NHS Employers. Members of the Society of Radiographers are eligible for cover under the SoR Professional Indemnity Insurance (PII) scheme as long as they are in membership both at the time of an incident and that of a claim. Please note The SoR PII scheme only applies where there is a contract of employment in place. Members must also be working within their Scope of Practice and in accordance with the College Code of Professional Conduct. Full details can be found here.
Our frequently asked questions about PII https://www.sor.org/learning-advice/employment-advice-and-support/indemnity-insurance may also be helpful.
If you have any specific queries with regards to PII please contact the PII administrator Liz Robinson [email protected].