Radiation Safety Policy and Procedures

The purpose of this policy is to promote the responsible use of radiation in the health care setting as well as to promote proper radiation safety practices.

Shielding

Students are encouraged to shield patients from unnecessary ionizing radiation to protect reproductive organs and/or bone marrow, as deemed necessary.

Failure to Shield

Unless shielding would endanger the patient, obscure pertinent anatomy, or compromise the diagnostic quality of the image, failure to shield appropriately may result in disciplinary action.

Students that perform a competency without shielding appropriately during the procedure or fail to provide protection for themselves, patient, or others through use of lead aprons, short exposure time, distance, and PMDs, may receive a point deduction under radiation safety.

Radiation Protection

  • Students are not to hold patients or an image receptor during an x-ray exposure.
  • If a patient requires assistance during a radiographic procedure to hold still, the person assisting the patient needs to be provided a lead shield.
  • Lead aprons and thyroid shields are to be used during all departmental and portable fluoroscopy procedures.
  • Students are to wear a lead apron regardless of the distance from primary beam.
  • For all portable radiographic procedures, 2 lead aprons must be provided, one apron for the student and one apron for the patient. All students must wear a full lead apron and maintain a six (6) foot distance from the primary beam when making the exposure.
  • When wearing a lead apron, the Personnel Monitoring Device (PMD) is to be worn on the collar, outside the apron.
  • All females (patients, caregivers, and/or parents) of childbearing age, are to be asked:
    • “Is there any chance you could be pregnant, trying to get pregnant, or potentially pregnant?", prior to producing radiation.
    • A positive response or an unsure answer requires the student to report the response to a qualified radiographer.

Repeat Radiographs

Unsatisfactory radiographs shall be repeated ONLY in the presence of a qualified radiographer, regardless of the student’s level. Repeats must be documented in Trajecsys.

Sanctions

Generally, disciplinary sanctions occur in the following sequence:

1. The first infraction will result in a written letter of warning that shall be provided to the student and filed in the student’s permanent record.

2. A second infraction of the same or different type will result in a two-day suspension. Any student who has been suspended shall remain on disciplinary probation for the remainder of the student’s enrollment at the School.

3. Any additional infractions may result in program dismissal.

Personnel Monitoring Devices (PMDs)

PMDs are to be worn at the collar level and cannot be worn for employment.

Students that lose or misplace their PMD must report the loss to the Program Coordinator Clinical Education Experience and the School Radiation Safety Officer as soon as possible.

Students are not allowed in clinic without their PMD.

The PMD is due by the due date (located on the device). Failure to turn in PMDs on time will result in the student taking responsibility for returning it to the School Radiation Safety Officer as soon as possible and a potential clinical grade reduction. Students that are absent from class must turn in their PMD the first day back to school to the School Radiation Safety Officer.

Radiation Dosimeter Reports

Radiation Dosimetry Reports are available quarterly and monitored by the School Radiation Safety Officer. Once the quarterly reports received, they are shared with the students, faculty, and staff within 30 days. Any unusual readings will be evaluated, and the student notified. Radiation Dosimeter Reports are permanently maintained by St. Mary's Hospital Radiology Department.