SErIES IAEA HumAn HEAltH SErIES IAEA Hum

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(i) (j) (k) Examine the availability, accessibility and contents of resuscitation resources; Discuss with staff and examine documentation regarding staff training and competencies for resuscitation; Check the availability of trained staff for resuscitation. 4.2.3.4. Image quality The audit team should: (a) (b) (c) (d) (e) (f) (g) (h) Review a sample of images from different examination procedures and assess the image quality; Interview staff regarding their awareness of factors contributing to image quality; Identify the radiographer responsible for the radiographic QA programme, and discuss their roles and responsibilities; Interview staff regarding their awareness of image quality evaluation criteria for various examination procedures; Review records of image quality audits, and records of analyses of rejected and repeat images; Discuss with radiography staff the feedback given to them about their individual performance; Check for the process regarding provision of feedback by radiological medical practitioners regarding suboptimal images; Check for the process for discussing image quality difficulties with the reporting radiological medical practitioner. 4.2.4. The imaging report The audit team should: (a) (b) (c) (d) Observe the reporting environment to confirm the presence of prior studies and reports, and reviews of them; Analyse a random sample of examination reports to assess their contents, including clinical indications, a description of the technique used, imaging findings and their correlation, and guidance for further management; Review a random sample of reports to confirm the presence of final signatures; Request a sample of reports in which untoward effects have been documented. 42
4.2.5. Report communication The audit team should: (a) (b) (c) (d) (e) (f) Review departmental process documentation for ensuring that all completed examinations are reported and that reports are distributed effectively; Review a sample of reports to assess whether reports are thorough and timely; Discuss with staff the methods of report communication; Check medical records for documentation that urgent and emergency results are communicated appropriately; Interview referring medical practitioners for their satisfaction with the timeliness, appropriateness and completeness of reporting; Review audit records of report communication. 4.2.6. Continuity of clinical care The audit team should: (a) (b) (c) (d) Examine departmental rosters for multidisciplinary clinico-pathologic correlation meetings, tumour boards and morbidity/mortality conferences, and results recording; Assess documentary evidence of attendance of radiological medical practitioners and other radiology staff at multidisciplinary clinicopathologic correlation meetings, tumour boards and morbidity/mortality conferences; Review examples of tracking of patient outcomes; Assess documentary evidence of internal and external audits of involvement of individual radiological medical practitioners in reviews of patient outcomes. 4.2.7. Accident and incident reporting The audit team should: (a) (b) (c) Examine documented protocols for handling of patient safety incidents and sentinel events; Review the log book of critical incidents, for example, sentinel reports, their analysis and resulting actions; Review the log book of serious patient safety incidents for the manner in which the incidents are reported, analysed and responded to; 43
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IAEA HumAn HEAltH SErIES no. 4 Comp
Page 3 and 4: COMPREHENSIVE CLINICAL AUDITS OF DI
Page 5 and 6: IAEA HUMAN HEALTH SERIES No. 4 COMP
Page 7 and 8: FOREWORD The application of radiati
Page 9 and 10: CONTENTS 1. INTRODUCTION . . . . .
Page 11 and 12: 5.1.3. Quality assurance processes
Page 13 and 14: 1. INTRODUCTION 1.1. CLINICAL AUDIT
Page 15 and 16: 1.1.3. Confidentiality of audits Co
Page 17 and 18: evidence based medical research is
Page 19 and 20: As a result of the comprehensive cl
Page 21 and 22: The facility/institution is respons
Page 23 and 24: 2.4.2. Review The review process wi
Page 25 and 26: 2.5.1. Title page and contents page
Page 27 and 28: 2.6. DISSEMINATION OF THE REPORT Th
Page 29 and 30: A QA committee should be establishe
Page 31 and 32: Lines of authority should be reflec
Page 33 and 34: —Medical support equipment such a
Page 35 and 36: (g) (h) (i) Make an assessment of t
Page 37 and 38: (c) (d) (e) (f) Examine the facilit
Page 39 and 40: (c) (d) Consider policy in regard t
Page 41 and 42: equire a written policy and procedu
Page 43 and 44: Once examination scheduling has bee
Page 45 and 46: Documentation of the details of the
Page 47 and 48: There should be a radiographer resp
Page 49 and 50: —Recorded; —Systematically eval
Page 51 and 52: 4.2.1.5. Pre-procedure screening an
Page 53: (f) (g) (h) (i) (j) (k) (l) (m) (n)
Page 57 and 58: —Digital image receptors (compute
Page 59 and 60: (b) (c) (d) Ensuring that appropria
Page 61 and 62: 5.1.2.2. Occupational and public ex
Page 63 and 64: (f) (g) Performance criteria for al
Page 65 and 66: Dosimetry for those subjected to ra
Page 67 and 68: 5.2.1.3. Management support The aud
Page 69 and 70: (b) (c) Discuss the facility’s po
Page 71 and 72: (g) (h) (i) Discuss with the medica
Page 73 and 74: Professionals engaging in such prog
Page 75 and 76: 6.2. THE AUDIT PROGRAMME 6.2.1. Edu
Page 77: (d) (v) Regularity of research meet
Page 80 and 81: Six months before audit Audited ins
Page 82 and 83: Day 1: Morning: All audit team memb
Page 84 and 85: Appendix III AUDIT REPORT FORMAT: S
Page 86 and 87: Appendix IV AUDIT REPORT FORMS The
Page 88 and 89: Audit criteria Adequacy Comments Su
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Audit criteria Adequacy Comments Su
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5.3. AUDIT REPORT FORMS FOR TECHNIC
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6.3. AUDIT REPORT FORMS FOR EDUCATI
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Appendix V NOTES ON PHYSICIST MEASU
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V.2.3. Other measurements The other
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[16] COMMISSION OF THE EUROPEAN COM
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Annex I APPLICATION FORM IAEA Clini
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Department Vision Statement and imm
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List of equipment Equipment type Id
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Annex II LIST OF ITEMS REQUESTED TO
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Annex III EQUIPMENT-SPECIFIC CHECKL
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Form RXR — Items to be reviewed b
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Form RXR — Items to be reviewed b
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Form FIF — Items to be reviewed b
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FORM FOR A MAMMOGRAPHY QA PROGRAMME
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Form MAM — Items to be reviewed b
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Form CTQ — Items to be reviewed b
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FORM FOR A SCREEN-FILM AND PROCESSO
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FORM FOR A COMPUTED OR DIGITAL RADI
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FORM FOR A VIEWING CONDITIONS (ANAL
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FORM FOR A QA PROGRAMME FOR HARD CO
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Form DPQ — Items to be reviewed b
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FORM FOR A QA PROGRAMME FOR ULTRASO
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FORM FOR A QA PROGRAMME FOR MRI For
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Form MRI — Items to be reviewed b
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TECHNIQUE OBSERVATION SHEET Radiogr
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Tube focus to tabletop distance d F
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K i Patient: Radiographic Calculati
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Manufacturer of phantom: __________
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P KA Patient: Fluoro 1 DETERMINATIO
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Phantom: MGD 1 CALCULATION OF INCID
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Phantom: CT1 MEASUREMENT OF C a,100
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REFERENCE TO ANNEX IV [IV-1] INTERN
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CONTRIBUTORS TO DRAFTING AND REVIEW
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Korea, Republic of KINS Inc., Infor
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