SErIES IAEA HumAn HEAltH SErIES IAEA Hum

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—Digital image receptors (CR or direct digital); —Image display devices (film viewing boxes, workstations and display monitors); —Image viewing conditions; —Hard copy devices (printers and film processors); —Digital scanners and storage systems. 5.2.1. Infrastructure 5.2.1.1. Organizational structure The audit team should: (a) (b) (c) (d) (e) Identify the facility’s medical physicist; Identify the RPO and their deputy, if applicable (a deputy being essential if the RPO is not a full-time member of the facility), and discuss documented qualifications and training; Review the existence, membership and work of the Radiation Safety Committee; Review the radiation protection manual to ensure that it is current, that it documents all relevant areas of radiation protection, and that it is regularly reviewed; Seek clarification on the organization of radiation protection from the director of the facility and/or the RPO, as necessary. 5.2.1.2. Personnel The audit team should: (a) (b) (c) (d) (e) Review the role of medical physicists in directing and supervising QA activities, radiation protection practice and dosimetry; Review the role of the RPO with respect to occupational radiation protection and radiation protection of the public; Review the duties of radiology facility staff to determine their role in QA processes, radiation protection and patient dose data collection; Review the syllabus and frequency of hospital based radiation protection and safety training programmes for staff; Determine, through interaction with staff, their practical knowledge of radiation safety principles. 54
5.2.1.3. Management support The audit team should: (a) (b) (c) (d) Review the structure of radiation protection and safety and technical QA management and corrective actions within the radiology facility through written records and discussion with staff; Determine if sufficient time is provided to the QA radiographer(s) and the medical physicist to carry out their activities and corrective follow-up; Determine if management supports necessary corrective actions; Discuss the strengths and weaknesses of the radiation protection and safety and QA programmes with the facility management, medical physicist and QA radiographer. 5.2.1.4. Documentation The audit team should identify documentation on policy and procedures for QA, radiation protection, dosimetry and general matters as well as reports of regulatory inspections and voluntary audits, and confirm that they are accessible. 5.2.2. Radiation protection and safety 5.2.2.1. Medical exposure The audit team should: (a) (b) (c) Review facility policies on: (i) Risk assessment and management; (ii) Estimation of typical patient dose levels from common examinations and comparison of them with relevant DRLs; (iii) Optimization of imaging examination; (iv) Size adjusted imaging techniques for paediatric patients; (v) Pregnant or potentially pregnant patients; (vi) Adverse patient dose incidents. Examine policies for comforters and carers in controlled areas and supervised areas or other hazardous areas, to ensure that they are consistent with legal requirements or relevant guidelines. Clarify with the facility director, senior radiographer and medical physicist any aspects of the facility’s policy for radiographic examinations of infants, children or pregnant patients, as necessary. 55
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IAEA HumAn HEAltH SErIES no. 4 Comp
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COMPREHENSIVE CLINICAL AUDITS OF DI
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IAEA HUMAN HEALTH SERIES No. 4 COMP
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FOREWORD The application of radiati
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CONTENTS 1. INTRODUCTION . . . . .
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5.1.3. Quality assurance processes
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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 and 54: (f) (g) (h) (i) (j) (k) (l) (m) (n)
Page 55 and 56: 4.2.5. Report communication The aud
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: Dosimetry for those subjected to ra
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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