Doc menu

APPENDICES

Appendix I    
 

Typical staff induction checklist
General

  • Read local rules
  • Read IRMER Employers Procedures

Examination rooms / treatment / simulator units

  • Read Work Instruction Files (standard operating procedures) relevant to unit and activities associated with unit
  • Switching on and off procedures
  • Machine QA
  • Contingency procedures
  • Use of equipment
  • Techniques relevant to unit
  • Use of radiology information system / record and verify system
  • Staff organisation
  • Consent process
  • The request card / treatment prescription
  • QA procedures

Patient care

  • Review clinics
  • Patient information
  • Departmental skin care
  • Support services, nursing, dietician, Macmillan staff
  • Post treatment follow up clinics

Additional

  • Appointment booking system
  • Hospital transport
  • Telephone procedure/ bleep system
  • Doctors clinics
  • Private patient procedures

Radiation protection

  • Staff monitoring procedures
  • Departmental contingency plans
  • IR(ME)R procedures
  • Incident reporting procedures and documentation

Health and safety

  • Departmental procedures
  • COSHH
  • Emergency  / crash procedure

 

Appendix II         

 

Radiation Health & Safety Checklist

Radiations Regulations:
Is a copy of the Ionising Radiation Regulations 1999 available to staff for reference?

Is a copy of the Ionising Radiation (Medical Exposure) Regulations 2000 available to staff for reference?

Are the Local Rules available to staff for reference?

Are the Local Rules adequate ie do they indicate as a minimum:

  1. Details of Radiation Protection Supervisor?
  2. Details of Radiation Protection Advisor?
  3. Details of Prior Risk Assessments?
  4. Details of Contingency Plans?
  5. Details of the procedure for declaration of pregnancy for female staff and the subsequent risks?
  6. Details of Controlled Areas in department?
  7. Details of Supervised Areas in department?
  8. Details of the procedure for incident reporting of an unintended radiation dose to patients / public / learners / other staff?

Departmental Environment:
Are there sufficient radiation warning lights and hazard signs?

Are the radiation warning lights working effectively?

Are all entrances visible from the control panel?

Is there a suitable range of personal protective equipment for radiation use available?

Is the personal protective equipment stored correctly?

Is the personal protective equipment checked regularly (e.g. QA leakage tests)?

Are there adequate warning notices to pregnant patients?

Staff Personal Dosimetry:
Are staff aware of their classification as radiation workers?

Is there a process for the retrieval of staff dose records from a previous employer?

Is there a procedure for personal dosimetry of staff within dept?

Is there a robust collection process of personal dosimeters?
    i) Do all staff comply with this process?

Is there a process for the recording of accurate and appropriate dose records of staff?

Is there a process in place for informing staff of their personal dose record?

Training:
Is there a robust checking procedure to ensure that staff are adequately trained?

Is there a robust training system of radiation protection procedures in place for new radiation staff?

Is this training recorded, continually updated and kept for reference?

Other:
Are non-radiation workers allowed access to radiation areas (e.g. general public, domestic / ancillary staff, learners?
If so:

  1.  Is there a robust training system of radiation protection procedures in place for new radiation staff?
  2.  Is this training recorded, continually updated and kept for reference? 
  3.  Is there a process in place for personal dosimetry?
  4.  Is there a process for the recording of accurate and appropriate dose records?

Is there a robust investigative procedure in place following the reporting of an unintended radiation dose to patients / public / learners / other staff?

If so, are staff aware of this investigative procedure?
 

 

Appendix III (i)
 

Ionising radiation risk assessment form – Diagnostic – example 1    (complete)       
 

 

 

 

 

Appendix  III (ii)

Ionising radiation risk assessment form – Diagnostic – example 2 

This form should be completed before the x-ray room, equipment or new technique is put into use

 

1 Radiation dose which could potentially be received can be taken as an indication of the risk. The employer must keep radiation doses as low as reasonably practicable and certainly less than any dose limits.  The annual effective dose limit is 1 mSv for members of the public and 20 mSv for staff working with radiation. For the population as a whole an effective dose of 1 mSv carries a risk of excess fatal cancer of 1 in 20,000.  This risk is similar to the risk from smoking 75 cigarettes, travelling 2,500 miles by car, or working in a typical factory for 2 years.

 

 

 

Appendix III (iii)

Example of ionising radiation risk assessment form                                                
– Generic – example 3

 

 

 

 

Appendix III (iv)

Risk Assessment Form (Radiotherapy) example 4

 

 

 

Appendix III (v)

Radiation Risk Assessment for Interventional Fluoroscopy Examinations (example 5)

Type of Procedure:   
Interventional examinations using fluoroscopic exposures e.g. angiography, angioplasty, nephrostomy, PTCs, stent insertions (ureteric, oesophageal, arterial, venous), varicele embolisations etc.

Location: Interventional X-ray room in the x-ray department

Workload: e.g. 5 sessions per week, 4 cases per session from the above procedures.

Staff Groups (and Others) Involved
Radiographers and Radiologists; Outside Specialists (Service engineers, medical physicists etc)
Radiology Sister
Radiography helpers
Ancillary staff (porters; cleaners; hospital maintenance staff etc.)
Patient escorts (either members of the public or other hospital staff)

Identified Radiation Risks
Risk of exposure to 50-120kV x-rays, either from the primary beam or from secondary radiation from the patient and c-arm tube head.

Control Measures for Routine Work
Designation of Area
The whole of the examination room is designated as a controlled area.
Dose to individuals in adjacent areas will not exceed 0.3mSv per year. 
Structural Protection
All walls, floors and doors are designed so that the controlled area does not extend beyond the room.
Separate control room built using adequate attenuation materials.
Engineering Controls and Warning Devices
Warning lights indicating mains on and expose conditions on patient entrances.
Warning signs demarcating controlled area and restricting access at all entrances.  Digital locks on patient corridor access into the suite.

Provision of PPE
Protective aprons and thyroid shields used by radiographic staff and anyone else required to remain within the controlled area during exposure (this will introduce a manual handling risk: see manual handling risk assessment).

Lead glasses should be used by the Radiologists.
Lead rubber table side drapes should be used for all interventional work.

Systems of Work (documented in Local Rules)
Radiographers and Radiologists; Outside Specialists (Service engineers, medical physicists etc)

Staff who are required to remain out in the room must wear protective lead aprons and thyroid shields and stand as far away as practicable from the c-arm and patient.

Lead glasses should be used by the Radiologists.
Lead rubber table side drapes should be used for all interventional work.

Radiography Helpers and Ancillary Staff (porters; cleaners; hospital maintenance staff etc.)
When the ‘mains on’ indication is on the above may only enter with the permission from radiographic staff.
Should not remain within the room during the exposure.

Patient Escorts
May only enter with the permission from radiographic staff.
Must remain in the control room during exposure with the exception of special circumstances, when instructions from radiographic staff must be followed.

Projected Dose
If control measures are followed, all staff and members of the public are likely to receive an annual dose in the ‘low’ category (effective dose<2mSv/year).  No staff should require designation as classified due to this work.

Training Requirements

Radiographers and Radiologists; Outside Specialists (Service engineers, medical physicists etc)
Professional training in radiation protection.
Read Local Rules.

Radiology Sister
In-house tutorial on radiation protection.
Read relevant section of Local Rules.

Radiography Helpers
In-house tutorial on radiation protection.
Read relevant section of Local Rules.   

Ancillary Staff (porters; cleaners; hospital maintenance staff etc.)
Read relevant section of Local Rules.

Audit Methods
Routine whole body personal monitoring for radiographers, radiologists, x-ray nurses and radiography helpers.
An appropriate investigation level as required under IRR99 Reg 8(7) is 2mSv in any calendar year.

Maintenance and Testing of Engineering Controls
Warning lights and safety features tested during routine service (3/4 monthly).

Additional Precautions for Pregnant/Breastfeeding Women or Young/Inexperienced
Employees

Pregnant/Breastfeeding Women
No special measures required.

Young/Inexperienced Employees
Should always work under supervision until assessed as adequately trained.

Possible Accident situations and Required Contingency Arrangements
Hazard

X-ray production fails to terminate at end of set time; Non-release of footswitch.

Contingency Arrangement
Unit must be disconnected from mains supply, using the emergency stop button.

Hazard
Unprotected personnel inadvertently in controlled area during exposure.

Contingency Arrangement
Exposure halted if possible (with due regard to examination requirements).  Person to be removed or provided with protection as appropriate.

Review Arrangements
This risk assessment is subject to annual review by the RPS, and must be included in the report to the Radiation Protection Committee.

Prepared by:    ___________________________
    
Signature: __________________________     Date: ____________

Agreed by RPA: ________________________
        
Signature: ________________________     Date: ____________

 

 

Appendix III (vi)

Cardiac Catheterisation Laboratory Radiation Risk Assessment for Cardiac Examinations (Example 6)


Work Practice

Type of procedure: 
Patient examinations involving Cardiac Angiography and Pacemaker insertions

Location:
Cardiac catheterisation laboratory within the Cardiology Department.

Workload:
5 angio sessions per week, 5 patients per session as typical.
1 pacing session per week –typically 2 patients per session.
1 angioplasty session per week, 3 patients per session.

                      
Staff groups (and others) involved.
Radiographers
Cardiology Nurses
Cardiologists
Cardiac technicians
Outside specialists (service engineers, medical physicists etc)
Ancillary staff (Porters, Cleaners, maintenance staff etc)
Patient escorts (either members of the public or other visiting hospital staff)

Identified radiation risks
Risk of exposure to 50 - 120 kV X-rays from secondary radiation from the patient and tube head and from the primary beam for operators.

Control measures for routine work

Designation of area
The catheter laboratory (procedure room, control room and equipment room) is designated as a controlled area and is designated permanently as a controlled area .The area is defined by the structures of the room including doors/chicanes and entrances.

Structural protection
Walls, floors, doors etc designed so that controlled area does not extend beyond the laboratory unit and so that staff working in adjacent areas receive less than 0.3mSv p.a.
Control room protected by a screen.
Ceiling suspended protective shield in the procedure room for operators
Mobile screens provided for nursing staff.
Table side drapes to protect legs of those stood close to table.

Engineering controls and warning devices
Warning lights at all entrances to the controlled area indicating “controlled area” when mains on and “X-rays on” during expose condition. Also X-rays on warning light to be provided at entrance from control desk through to X-ray room.
Warning signs demarcating controlled area and restricting access at all entrances to controlled area.

Provision of PPE
Protective aprons and thyroid collars available –checked prior to first use then checked yearly and documented.

Systems of work

Radiographers, Nurses, Cardiologists
Only essential staff remain in the procedure room during exposure/examination.
Other staff stay in the protected control room .
All staff remaining in the procedure room to wear protective apron (with thyroid and eye protection if appropriate).
Staff stand as far away from X-ray tube and patient as practicable and on the intensifier side (rather than tube side) of the patient where appropriate.

Clinician at table performing the procedure uses ceiling mounted protective shield and table side protection where possible.
Others in room e.g. assisting nurses to make us of mobile protective screens when possible.
Only one patient examined at any time.

One operator uses pump injections for the procedure–Cardiologists stand behind mobile screen during acquisition , Radiographer screen, injects and acquires for the coronary series.

Outside specialists (service engineers, medical physicists etc)
Only essential staff remain in the procedure room during exposure.
Other staff stay in the protected control room.
All staff remaining in the procedure room to wear protective apron (with thyroid and eye protection if appropriate).
Operators at table use ceiling mounted protective shield where possible.
Staff stand as far away from X-ray tube and patient table as practicable.

Ancillary staff (Porters, Cleaners, Hospital maintenance staff etc)
May only enter the laboratory with the permission from a member of the radiographic staff.
Do not remain within the procedure room during exposure.

Patient escorts
May only enter with the permission from radiographic staff.
Do not remain within the procedure room during exposure.

Projected dose
If control measures are followed all members of staff likely to receive annual effective doses < 1mSv per year (low dose category) and extremity dose < member of the public dose limit.

Staff working in the adjacent areas likely to receive annual effective doses < 0.3 mSv per year.

No staff should require designation as classified due to this work.

Training requirements

Radiographers, Cardiologists , Outside specialists (service engineers, medical physicists etc)
Professional training in radiation protection/updates.
Read Local Rules

Nurses
Radiation protection tutorial from RPS
Read Local Rules

Ancillary staff (Porters, Cleaners, maintenance staff etc)
Read relevant section of Local Rules
To be instructed in precautions by appropriate line manager
Regular staff to have interview with RPS to ensure Local Rules understood.

Audit methods
Routine whole body personal monitoring for cardiologists, radiographers, cardiac technicians and cardiology nurses

Visiting cardiologists with workload <50 cases per year asked to bring the personal monitors from their main radiation Employer. Workload to be audited to ensure all clinicians with workload > 50 per year are monitored separately.

An appropriate investigation level as required under IRR99 Reg 8(7) is 2 mSv in any calendar year.

Periodic extremity and eye dose monitoring when appropriate. Initially cardiologists and scrub nurses to be provided with eye badges for first 6 months and results reviewed.

Maintenance and testing of Engineering Controls
Warning lights and safety features tested during routine service (three monthly) and documented .
Any engineering controls that require maintenance should be maintained in efficient working order and good repair.
Any problems noted in routine use should be reported to the RPS. A fault log should be maintained in the laboratory.

Extra precautions for pregnant women and inexperienced Employees

Pregnant  women
RPS perform individual risk assessment.

Inexperienced Employees
Should always work under supervision until assessed as adequately trained.

Possible accident situations and required contingency arrangements

Hazard
X-ray production fails to terminate at end of set time/release of footswitch..

Contingency arrangement
Unit must be disconnected from mains supply.

Hazard
Unprotected personnel inadvertently in room during exposure

Contingency arrangement
Exposure halted if possible (with due regard to examination requirements). Person to be removed or provided with protection as appropriate.

Review Arrangements
Risk assessment to be reviewed by RPS annually, and findings included in report to the Radiation Protection Committee.

Agreed by Radiation Protection Supervisor:
Name:         
    Signature    ____________________________
Date:        ____________________________

Agreed by Radiation Protection Adviser:

Name:        ___________________________________________
    Signature    ___________________________________________
Date:        ___________________________________________

 

Content tools

Accessibility controls

Text size

AA A

Colour