A. The CQC provides detailed information on when to report an IRMER incident.
On this page you will find a link to an online incident report form. Once the form is submitted, you will receive an automatically generated email acknowledgement, including an IRMER notification reference number. This number has to be used in all subsequent dialogue with the CQC. You are advised to contact the CQC if you do not receive this confirmation email.
If you have any difficulties, please contact the IRMER desk on 020 7448 9039 or via email at [email protected].
An example of the normal sequence of events when a radiation incident (IR(ME)R) notification has been made to CQC (England):
A: There is an epidemiological research article (free of charge) in the British Journal of Cancer entitled: Bunch KJ, Muirhead CR, Draper GJ, Hunter N, Kendall GM, O'Hagan JA, Phillipson MA, Vincent TJ, Zhang W. Cancer in the offspring of female radiation workers: a record linkage study. British Journal of Cancer (2009), Volume 100, Issue 1, pages 213-218. available for download here.
Although the radiation worker subjects involved in this research study are from the nuclear, research and industry sectors (who tend to be classified radiation workers) and NOT in healthcare (NOT radiographers), the conclusion that there is no evidence of an increased risk of childhood cancer associated with maternal preconception radiation work is heartening. However, there does seem to be limited evidence of a weak association between maternal radiation exposure during pregnancy and childhood cancer in offspring. A similar study that did involve radiographers found NO such evidence of excess cancer in the radiographers' offspring - see Roman E, Doyle P, Ansell P, Bull D, Beral V (1996) Health of children born to medical radiographers.
Occup Environ Med 53: 73-79 Many female radiographers have contacted the Society & College of Radiographers to express concerns regarding anxieties of occupational radiation exposure during pregnancy which has prompted information about working whilst pregnant to be posted on the SoR website. The SCoR also wishes to report that a new publication entitled "Pregnancy and work in Diagnostic Imaging" from the British Institute of Radiology" (to which SCoR had input) will be available shortly.
HSE have produced a useful publication which is available here PDF
This should be read in conjunction with the SoR Pregnant staff handbook – available under the Health and Safety section of this website.
The International Committee of Radiological Protection (ICRP) has produced a very useful (and free) PowerPoint presentation relating to information surrounding exposure to ionising radiation and pregnancy (for staff and patients).PowerPoint
As explained in the guidance your written procedure should to apply to yourlocal risk group.This is the age at which it is considered there is potential for pregnancy. For example 12-55, meaning it would not apply to a 6-year-old or an 80-year-old person.
Work with your MPE to define the exposures or the range of exposures that may result in a dose that could be harmful to a fetus. So for example, it would not apply to a finger exposure. Apply the procedure to everyone in the defined risk group.
People aren’t all the same and unless we ask them, we can’t be sure everyone gets the same opportunity to receive safe care. The objective of the guidance is to support services to deliver inclusive care. This means no person should be at risk of being irradiated during pregnancy.
The guidance and the IPS form serve to ensure no person who may be pregnant is excluded. You may wish to continue with an existing procedure but, as with the measures recommended in the guidance, it should afford no less protection to any one individual. Unless you are already asking all patients in your defined local risk group then there is still a risk of accidental fetal exposure.
The recommendations in the guidance are to ensure the way we practice and the care we give is equal for everyone. Equity means ensuring there is opportunity for all individuals to access the same level of care. We do not believe the recommendations disadvantage any group. The pilot studies did not report that patients felt disadvantaged or offended by being asked about the possibility of pregnancy where it was appropriate to do so.
Yes. An employer can choose to use any written procedure if the procedure and the way it is appliedensures that trans or non-binary individuals can be assured of safe, effective and equitable care. Any professional can use their judgement but must work in line with their employer’s procedures. The same procedure should be applied to everyone in the same risk group.
Yes. Trans and non-binary (TNBI) people are represented in all communities not just large cities. It may be necessary to work with local TNBI groups to understand what the needs or barriers are to healthcare in your local area. Training should be tailored to meet the local need.
Q: What else can we do?
A: Speak to your MPE and the person who has the named legally responsibility, as the Employer, for IR(ME)R compliance in your organisation. Document the areas where you feel improvement needs to be made to achieve compliance. Use the guidance to support the case for change. The IR(ME)R regulators are often happy to give advice.
It is important that healthcare professionals know what data is being shared.
There is legislation and guidance around this which may inform your local discussions.
Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 on the protection of natural persons with regard to the processing of personal data and on the free movement of such data (United Kingdom General Data Protection Regulation) (Text with EEA relevance) (legislation.gov.uk)
Patients have a right to choose what information they disclose and this right must be respected. However, it is a requirement for employers to have written procedures to provide the individual to be exposed with adequate information relating to the benefits and risks of the exposure. If we do not provide this information, where it is practicable to do so, it may not be possible to gain informed consent.
Do not assume the patient knows the risks. They may not know how to ask the question or may be fearful of disclosing the information. Radiographers should be trained and competent to ensure the patient is making a fully informed decision. As long as a radiographer has followed the employer’s written procedure and this procedure meets the requirements of IR(ME)R then a patient’s decision should be respected.
They will have been fully informed of the risks as part of the procedure so in this case the exposure may still be justified or may be postponed. This is a decision for the IR(ME)R practitioner considering the patient’s wishes.
Please note regulation 19 of IR(ME)R - Defence of due diligence. All reasoned decisions should be documented. All patient responses should be documented where it is appropriate to do so.
The benefit and risk conversation needs to be managed sensitively in this age group and the language chosen may differ. The number of children identifying as trans is increasing and so this is an important consideration. Children may give informed consent as long as the information is communicated appropriately. For more information, please see Obtaining consent: a clinical guideline for the diagnostic imaging and radiotherapy workforce updated_22_jan_2020_131117_002.pdf_2 (sor.org)
This will depend on your local procedure, who is trained to undertake the test and deliver the information, and how relevant the result is in the context of justifying the dose you are delivering.
The pilot studies were all undertaken in large cities. If you feel you work in an area where the demographic is likely to be very different you may wish to run a local pilot and adapt your procedure accordingly. Please be aware that you will still need to meet the legal requirements.
The requirements of IR(ME)R came into effect on 6th February 2018. Some employers will have already adopted these measures and have been compliant since this date. The guidance helps with compliance for those who are finding it challenging to meet the requirements or who have been advised that their existing procedures are not compliant.
This will vary depending on the demographic of your team. It is recommended that you assess the gaps in knowledge and the skill mix in your local workforce and address any specific learning needs. During the pilot studies, it was found that explaining the meaning of the terms used in the guidance glossary gave employees more confidence communicating with Trans and Non-Binary (TNBI) people. Key points were around not being afraid to ask, listening and understanding the needs of the patient, not making assumptions and apologising and moving on if you get things wrong.
This is a really good question. Consent is generally considered to apply to a single episode of care and the guidance recommends applying secure measures to ensure any disclosed information about gender is not shared without the consent of the patient. In the case of multiple events on the same day you should have a local procedure for how this information is stored and shared and importantly this should be communicated to the patient and their consent gained to do so.
Please feel free to adapt the forms to your local needs but we do ask that the SoR is acknowledged as the original source for clarity.
Unfortunately, translation into all the languages spoken in the UK is prohibitively complex and very costly for a member funded organisation. The SoR is happy for anyone to translate the documents as long as the SoR is acknowledged as the original source for clarity.
As explained in the guidance, the referrer may not lawfully share information
There is a legal process in England for changing gender in medical records. Please refer to the guidance for more information. Please note that a trans male may have a male gender marker and therefore automatic gender alerts may not be appropriate.
Q: Quite a few departments now offer text reminder services, has there been consideration to provide an electronic link to this information so that these individuals are pre informed before hospital visits that they may be more inclined to offer the information up freely?
The more opportunity patients have to read and understand the information related to their safe care the better. An electronic link to the form could be helpful if the accompanying information about why the questions are being asked is available. You must also consider how you record the response and who has access to it. It is important to maintain confidentiality and to remember the patient may only be consenting to this information being shared for a single episode of care.
The IPS form has been designed to be used for every patient within your identified local risk group. Please see the guidance for more information.
We considered writing example employers’ procedures but after wide consultation it was acknowledged that services vary and what might be appropriate for one would not suit another. Instead, the guidance includes important considerations to include in your local written procedures (appendix 1 and 2).
The guidance is aimed at everyone in the radiographic workforce, and we would hope that educators and radiographers work together with students to ensure inclusivity becomes part of our everyday practice and behaviour. It is important to open a conversation if you feel this is not happening.
A: There is a very useful power-point presentation about avoiding radiation injuries in interventional radiology. Available at: www.icrp.org
Q: Within my Trust, my role is Lead Radiographer for radiation protection governance and compliance. I oversee compliance of the IR(ME)R procedures and local rules. We have an organisational policy for non-medical referrers and none can refer without attending a radiation awareness presentation but I noticed in Synergy recently an advert for a course on IR(ME)R for non-medical referrers being run by the Society and College of Radiographers (SCoR). The advert refers to an agreement between SCoR and other AHP bodies regarding the level of radiation protection training required - I would like to know what is involved in this training.
A:The published guidance (based on previous SoR guidance) entitled “Clinical Imaging Requests from Non-Medically Qualified Professionals” has been agreed by SCoR with the Royal College of Radiologists, the Royal College of Nursing, the Chartered Society of Physiotherapists, the General Chiropractic Council and the General Osteopathic Council and is available on the SoR website. Although it is not mandatory under IR(ME)R for referrers to receive formal training, clinical imaging departments are advised in this publication to ensure that non-medically qualified referrers have received appropriate 'training' which is documented in accordance with local clinical governance procedures. SCoR, as the professional body for radiography, believes it appropriate that it leads in the provision of such 'training' and has organised a study day for non-medical IR(ME)R referrers. Also see IR(ME)R section.
The following topic areas are covered during the study day:
A:Yes. This is detailed in the publication L121 "Work with ionising radiation. Ionising Radiations Regulations 2017. Approved Code of Practice and guidance"
Essential content: Local rules must contain the following information:
A: Again, this is available in the same publication.
Optional content: Local rules may also contain a brief summary of the general arrangements of the following information:
A: Radiation employers (ie, employers who in the course of a trade, business or other undertaking carry out work with ionising radiation) are required, under IRR17, to designate as classified persons those employees who are aged 18 years or over and are likely to receive an effective dose in excess of 6mSv per year or an equivalent dose in excess of 15mSv per year for the lens of the eye or geater than 150 mSv per year for the skin or the extremities. (IRR regulation 21)
Where this is the case, employees will be informed that they have been classified and must be certified by a relevant doctor as fit for the work they are undertaking with ionising radiation
They must have their doses appropriately assessed and recorded. (IRR regulation 22).
A:For the protection of patients, the Ionising Radiation (Medical Exposure) Regulations 2017 (IR(ME)R) requires any IR(ME)R 'Operator' to undergo 'adequate education and training' to fulfil their (medical exposure) role – this would also apply to the ODP that is mentioned.
To undertake education and training to act as an 'Operator' would be to have demonstrable recorded evidence which would satisfy Schedule 3 of the IR(ME)R. It is theoretically correct that any individual can be given education and training (that includes both theory and practical training) to be able to be 'entitled' by an IRMER Employer as an 'Operator' (this is still necessary for even doing the fluoroscopic tasks in theatre). Radiographers, by virtue of their undergraduate training, already have this demonstrable evidence of training.
The other issue is, before each fluoroscopy procedure (exposure) is undertaken, it must first be 'justified' by the IRMER Practitioner – therefore in the theatre, it must be clear who would be providing this justification. Justification is the responsibility of the IRMER 'Practitioner' and the training for this may be greater. Again, Radiographers (usually more senior), have this demonstrable evidence of training. If the 'Practitioner' is to be the Surgeon, then the IR(ME)R Employer must ensure that the surgeon has also received the education and training necessary (to also satisfy Schedule 3 of IRMER) and will hold a record of those entitled to act as “Practitioner”.'
The ODP could act as an 'Operator', alongside the 'Practitioner', but they must take legal responsibility for monitoring and minimising radiation dose to the patient (ie, keeping within DAP “best practice' levels etc). Both the ODP and the surgeon must be made aware that these are legal roles – on the statute books under the Health and Safety at Work Act – and, as such, must take responsibility for the exposure to the patient. An important point to consider is that the surgeon is normally 'busy' dealing with the clinical requirements of the patient in theatre and does not always have the time to think about the technical and dosimetric elements of the radiation exposure procedure and, as such, would perhaps not be fulfilling the legal requirements of the IR(ME)R Practitioner role – something to think about with this proposal.
Additionally, the other Regulations that also come into force in this theatre scenario are the Ionising Radiations Regulations (IRR) 2017, in terms of protecting the radiation exposure to the staff involved in the theatre session; the QA of the equipment being used and also in taking responsibility for the controlled and supervised areas – there is a need to have the adequate training to fulfil these Regulations too. Again, a Radiographer does by virtue of their undergraduate training and education.
Q: This HEI is reviewing the radiography degree educational programme and one of the questions that had come up, from an admissions point of view, is if students still have to be 18 years old to go out on clinical placement.
Do you know of any reasons why radiography students cannot start at 17 years?
A: SCoR are not aware of any age restrictions for entry into radiography education programmes, there used to be with the old DCR but SCoR have not imposed any now.
Radiography students and radiographers are not being 'classified' as radiation workers under IRR 2017, but there may be some differences within different clinical departments from their Local Rules point of view, please check with each clinical placement site that they agree with you about sending under 18 year olds on clinical placement — the RPS/RPA for each department will be able to help.
IR(ME)R is only about patients and does not affect potential doses to students/staff.
If you are employed by the NHS you may access free learning on the E-Learning for Healthcare website and there is an e-IR(ME)R module.
Sue Barlow (a radiographer) runs particular IR(ME)R courses in IR(ME)R Theory for DXA Operator and IR(ME)R Theory for Mini C Arm Training her e-mail address is [email protected]
M&K Update run an IR(ME)R one day course.
A: SCoR do know of other (registered) staff groups being trained to use image intensifiers, although in cardiac work they are static units. Mobile units potentially present a greater radiation hazard. We cannot prevent this, however, we do remind people that the person must be adequately trained as an 'Operator' under IR(ME)R.
There is an issue around who is the 'Practitioner' under IR(ME)R, ie, who provides the justification for the exposure. A radiographer by virtue of their qualifications and HCPC registration can do this. Many medics will claim that they are the IR(ME)R Practitioner, likewise they must be trained in this role. We make the observation that it is difficult to be operating on someone and monitor the radiation dose to the patient and all staff at the same time.
SCoR advises that the theatre staff should work with the radiography department to ensure that there is adequate back-up and advice available.
There are programmes that are looking at 'generic' working in cardiac catheter labs, but the system of supervision and availability of expert advice is fundamental to these developments. Also, the nurses or electro physiologists involved generally only take on the role of Operator as the cardiologist is the Practitioner.
A: This is an important point that relates to the concept of asymptomatic screening or Individual Health Assessment.
The Department of Health has published a working party report entitled ‘Justification of Computed Tomography (CT) for Individual Health Assessment’. https://www.gov.uk/government/publications/use-of-ct-scanning-to-carry-out-individual-health-assessments
The report recommends circumstances when it may be justified to use CT scanning on individuals with no symptoms and outside of national screening programmes.
The working party that produced the report was recruited by the Royal College of Radiologists and the Royal College of Physicians.
SCoR Director of Professional Policy Charlotte Beardmore welcomed the report.
She said: “The SCoR has been concerned about self-referral and life-style screening for some time. We welcome these recommendations which discourage scans on people who are unlikely to benefit and encourage clear care pathways.
"However, we believe that self-referral for diagnostic imaging outside a nationally regulated health screening programme is inappropriate and unnecessary.”