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RADIOLOGY MANUAL DATE OF ISSUE: 01.01.2017

DATE OF LAST UPDATION:

DOC. No.: NIMS/MAN/02 01.05.2021

DEPARTMENT OF RADIODIAGNOSIS
SCOPE:
To establish set of written guidelines for the effective management of patient coming to the
department of Radio-diagnosis in an ethical and professional manner

PURPOSE:
 To guide staff members regarding protocols and policies to be adhered to ensure prompt
and error free management of outpatients, inpatients as well as Emergency patients at
department of Radio-diagnosis.
 To guide staff members to adhere to hospital policies to comply the national and hospital
safety policies to ensure zero errors as well as to abate any sort of safety risk and
emergencies
 To guide staff members to follow policies and protocols to monitor, manage and handle
all equipments in a safe and effective manner.

SCOPE OF IMAGING SERVICES

All Radiology services are functioning 24 hours a day. Scope of services of the department
includes:

 X Ray radiography (Imaging) – 2 fixed and one portable

 Ultra Sound Scan - 2
 Computed Tomography (CT) Scan
 C-Arm
Interventional procedures;
 FNAC
 Aspiration
 IVP Barium studies
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RADIOLOGY MANUAL DATE OF ISSUE: 01.01.2017

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 KINDLY ENTER OTHER SCOPE OF SERVICES

Services not available;

Mammogram
Nuclear medicines
Bone Mineral Density (BMD).

ORGANISATION OF THE DEPARTMENT

MANAGING DIRECTOR

MEDICAL ADMINISTRATOR

HOD – DEPARTMENT OF RADIO-DIAGNOSIS

RADIOLOGIST

RADIATION SAFETY OFFICER

SECTION INCHARGE

Sr. RADIOGRAPHERS

Jr. RADIOGRAPHERS

RECEPTIONIST (REPORT PREPARATION AT USG)

HOUSEKEEPING STAFF / ATTENDERS

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RADIOLOGY MANUAL DATE OF ISSUE: 01.01.2017

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 As per AERB guidelines only people with recognized qualification are recruited and
posted for imaging assignments.
 Round the clock service is ensured and staffs are deployed as per the patient flow
and departmental requirements.
 Annual Man power planning is done to ensure adequate mix of Radiologist, Senior
and Junior Radiographers and other technicians.

Responsibilities of Radiologist

 Obtain patient's' histories from electronic records, patient interviews, dictated reports, or
by communicating with referring clinicians.
 Gather medical information from patient histories.
 Collect medical information from patients, family members, or other medical
professionals.
 Prepare comprehensive interpretive reports of findings.
 Prepare reports summarizing patient diagnostic or care activities.
 Perform or interpret the outcomes of diagnostic imaging procedures including magnetic
resonance imaging (MRI), computer tomography (CT), positron emission tomography (PET),
nuclear cardiology treadmill studies, mammography, or ultrasound.
 Analyze test data or images to inform diagnosis or treatment.
 Operate diagnostic imaging equipment.
 Review or transmit images and information using picture archiving or communications
systems
 Communicate examination results or diagnostic information to referring physicians,
patients, or families.
 Communicate detailed medical information to patients or family members.
 Communicate test or assessment results to medical professionals.
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 Evaluate medical information to determine patients' risk factors, such as allergies to

contrast agents, or to make decisions regarding the appropriateness of procedures.
 Analyze patient data to determine patient needs or treatment goals.

Responsibilities of Radiology Incharge.

 Provides radiology services by directing and coordinating the services of radiology and
diagnostic imaging procedures; overseeing staff in operation of imaging equipment, such,
as X-Ray machines, Computerized Tomography (CT) scanners, or Magnetic Resonance
Imaging (MRI) equipment.
 Accomplishes radiology human resource objectives by selecting, orienting, training,
assigning, scheduling, coaching, counseling, and disciplining employees; communicating
job expectations; planning, monitoring, appraising job contributions; recommending
compensation actions; adhering to policies and procedures.

 Meets radiology operational standards by contributing information to strategic plans and

reviews; implementing production, productivity, quality and patient-service standards;
resolving problems; identifying system improvements.

 Meets radiology financial standards by providing annual budget information; monitoring

expenditures; identifying variances; recommending corrective actions.

 Conduct periodic departmental training for existing staff and orientation training for new
staff members.

 Improves quality results by evaluating accuracy and quality of images; providing technical
assistance; implementing new techniques, equipment and procedures.

 Provides statistical reports by controlling the collection of treatment and clinical data.
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 Provides a safe environment by monitoring radioactive exposure of staff and patients; keeping
staff and patient’s safe, maintaining records.

 Serves and protects the hospital community by ensuring adherence to professional standards,
hospital policies and procedures, statutory, legal and AERB requirements and National
Accreditation Board for Hospitals and Healthcare organizations (NABH) standards.

 Updates job knowledge by participating in educational opportunities; reading professional

publications; maintaining personal networks; participating in professional organizations.

RADIATION SAFETY OFFICER

The Radiation Safety Officer is responsible for recommending or approving corrective

actions, identifying radiation safety problems, initiating action, and ensuring compliance with
regulations.
The Radiation Safety Officer (hereafter referred to as the RSO) is also responsible for
assisting the Al Arif Safety Committee in coordination with Clinical Safety officer in the
performance of her duties.
RSO at NIMS is Mr. Dipu. (full name)
The responsibilities of RSO include:
 Annual review of the radiation safety program for adherence to ALARA (as low as
reasonably achievable) concepts.

 Quarterly review of occupational exposures. The RSO will review at least quarterly
external radiation exposures of authorized users and workers to determine that their
exposures are ALARA.

 Quarterly review of records of radiation level surveys. The RSO will review radiation
levels in unrestricted and restricted areas to determine that they were at ALARA levels
during the previous quarter
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 The RSO will schedule briefings and educational sessions to inform workers of ALARA
programs.
 The RSO will ensure that authorized users, workers, and ancillary personnel who may be
exposed to radiation will be instructed in the ALARA philosophy and informed that the
management, the Radiation Safety Committee, and the RSO are committed to
implementing the ALARA concept.
 Carry out routine measurements and analysis of radiation levels in the controlled area,
supervised area of the radiation facility and maintain records of the results thereof.
 Investigate any situation that could lead to potential exposures.
 Advise management on
o The necessary measures aimed at ensuring that the regulatory constraints and the terms and
conditions of the licence are adhered to.

o The safe storage and movement of radioactive material within the radiation facility.

o Initiation of suitable remedial measures in respect of any situation that could lead to
potential exposures.

o Ensure that test and maintenance schedules for safety related components and systems are
carried out in accordance with the schedule

o Report on all hazardous situations along with details of any immediate remedial actions
taken are made available to the employer and licensee for submitting to the Competent
Authority.

o Ensure that personnel monitoring devices are provided to workers in the facility, used as
required and securely stored in a radiation-free zone.
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o Supervise during maintenance and test procedures on systems and components or in areas
where radiation safety may be affected or where service/maintenance personnel may need
to be given special protection.

o Ensure that monitoring instruments are calibrated periodically.

o Maintain servicing, operation log books and associated QA records.

o Instruct the technicians and staff members on hazards of radiation and on suitable safety
measures and work practices aimed at ensuring that exposure to radiation is kept as low as
reasonably achievable.

o Developing suitable emergency response plans to deal with accidents and maintaining
emergency preparedness.

o Advise management and staff on modifications in working conditions of a pregnant

worker.

o Furnish to the licensee and the Competent Authority periodic reports on the safety status of
the radiation installation.

RESPONSIBILITIES OF RADIOGRAPHER

 Cross check patient identity before dispatching

 Maintain stock inventory.

 Maintain registers.

 Documentation

 Preparing duty schedule.

 Training of junior radiographers and technicians.

  Use TLD badge appropriately

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RADIOLOGY MANUAL DATE OF ISSUE: 01.01.2017

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  Safety aspects of Radiology to be followed like lead apron.

 In case of any software/hardware complaints report to IT dept.

 In case of any untoward incident in the department, initiate an incident report timely.

 Adhere to NABH standards, Quality and Infection control practices and take part in
Quality improvement activities.

REQUESTING OF INVESTIGATIONS

 All requests for Radiology investigations are sent to the department in a standardized
requisition format for each investigation as X-ray, Ultrasound, CT etc.
 The referring doctor enters the patient details in the requisition form along with
provisional diagnosis. The details required include:
o Patient Name
o MRD Number
o Age/ sex
o Date and time of reporting
o Name and signature of requesting doctor with seal
o Investigation to be performed with specifications on view of the image
o Part to be investigated with side / views, directional specifications etc.
 In case of Outpatients and patients from emergency department, the request form is sent
to concerned department via patient / bystander / hospital patient relations staff /
secretaries of OPD.
 In case of inpatients, the request is done in patient medical records as well as in
requisition form which will be sent to radiology department through nursing aid.
 Inpatients will be called for investigation once request form is received at radiology or
approximate time of reporting is informed to the concerned nursing station where the
patient is admitted.
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PATIENT FLOW MANAGEMENT

 Walk-in patients from OPD

 All walk in patients reports to CT/ MRI room after getting registered for their
investigations.
 They are requested to wait for their turn once identification and required
documentation is completed.
o Daily register is updated for Patient details including Name, MR Number,
Age/sex, Provisional diagnosis, referring doctor name, date and time of
arrival etc. after confirmation of identity with Registration card and
invoice.
 Patients from Emergency department
 Patients reporting at CT/MRI whether stable or unstable, is given priority for
scanning irrespective of token number of other waiting patients.
 Patient identity is duly confirmed and taken for scanning upon registering and
entry in daily register maintained.
 Stable patients if vulnerable the following shall be followed;
 They shall be transported in a wheel chair / bed with belt fastened.
 It shall be ensured that no body parts are projecting outside liable for hit and
causing injury.
 Transport shall be with bystander accompanying the patient.
 If no patients from emergency department or priority notice for a patient waiting
for scan from their doctor, then vulnerable patients are given priority for
undergoing CT/MRI Scan.
 Patients admitted in ward (inpatients)
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 Inpatients are brought for scanning after prior appointment from the concerned
ward / nursing station based on the priority notice of the treating / requesting
doctor.

TURNAROUND TIME FOR INVESTIGATION REPORTS

i. X-Ray film is ready within one hour from reporting time

ii. CT Scan; Brain – film within 30 minutes and report within 2 hrs

iii. CT body film with in 2 hrs and Report within 24 hrs

iv. OTHER PROCEDURES TAT

v. Ultrasound; Result available 30 minutes after the procedure

vi. Outsourced services; results in 24hrs after reporting by patient.

CRITICAL REPORT ALERT INTIMATION

The test results beyond the normal variation with a high probability of a significant
increase in morbidity and/or mortality in the foreseeable future and requires rapid
communication of results for determination of intervention.

 Results are communicated over phone to the doctor concerned or his team or if doctor is
not reachable it is informed to nurse in charge for further processing within one hour of
the report or at the earliest possible time.

 Log book is maintained in Radiology department as well as nursing stations to document

critical value alert communications

 Intimation includes name of patient, MR Number, date and time of investigation,

investigation done, critical report, name of the person conveying the critical alert, name
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of person receiving the communication, date and time of communication and readback
done to confirm the critical value / report communicated.

 List of possible critical cases is kept with the imaging division for reference.

LIST OF CRITICAL DIAGNOSES INCLUDING OUTSOURCED SERVICES

Anatomical area Modality Diagnosis
CNS CT/MRI Cerebral hemorrhage/ hematoma
CT/MRI Herniation Syndrome
CT/MRI Acute stroke
CT/MRI Intracranial Infection/empyema
CT Complex skull fracture
CT Unstable spine fracture
MRI Spinal cord compression
NECK CT Airway compromise
CT/MRI Carotid artery dissection
CT/MRI Critical carotid stenosis
CHEST X-RAY/CT Tension pneumothorax
X-RAY/CT Aortic dissection
CT Pulmonary embolism
X-RAY/CT Ruptured aneurysm or impending rupture
X-RAY/CT Mediastinal emphysema
ABDOMEN X-RAY/CT Free air in abdomen (no recent surgeries)
X-RAY/CT Ischemic bowel (pneumatosis)
USG/ CT Appendicitis
USG/CT Portal venous air
X-RAY/CT Volvulus
USG/CT Traumatic visceral injury
USG/CT Retroperitoneal hemorrhage
Uro Genital X-RAY/CT Bowel Obstruction High Grade/Complete
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USG Ectopic Pregnancy

USG Placental Abruption
USG Placental Previa ( near term)
USG Testicular or ovarian torsion
USG Fetal Demise
Bone X-RAY/CT Fresh fracture
General X-RAY/CT Significant Line/ Tube Misplacement

REPORTING OF RESULTS

Results are reported in a standard format for all imaging tests.

Images for X-Ray and scan are made available to individual doctors through Picture
Archiving and Communication System (PACS) in the designated MRD number slot.

For X-ray normally film is issued to the patients/ doctors concerned at request.

Report for CT / MRI will be reported within the specified TAT.

Where report from radiologist is desired like insurance cases etc., it is issued by
radiologists in a standard format.

All reports from out sourced are issued in the standardized format of the outsourcing
agency. They are not modified in any aspect by the hospital authorities.

RECALLING OF REPORTS

In case of Reporting Error; wrong reports issued from the department will be recalled
Reporting error is first informed to the treating physician directly.
Nursing station will be intimated next and report issued will be recalled.
Corrected report will be issued later on
Reporting Errors happen at Radiology department due to the following reasons:
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o Wrong report / film issued to a patient

o Wrong report entered
o Wrong entry in report format: wrong part, wrong findings, wrong L/R
markers etc.
o Patient identifiers entered wrong.
Reporting errors are identified by department staff/ doctors / nursing staff / patients and is
informed to the concerned department.
In case of Inpatient, the wrong reports are collected from the nursing station and
corrected reports are handed over.
In case of Outpatient, the information will be communicated with the referring consultant
and the patient will be contacted directly in their registered phone number in coordination
with public relations department to recall the report and corrected report will be handed
over or mailed to the email provided.
An incident report will be generated from the department/ doctor / nursing station to
analyse the error and take action to prevent similar occurrences in future.

LEGAL AND STATUTORY COMPLIANCE

NIMS Medicity complies with all legal requirements for the setting up and functioning of the
Department of Radiodiagnosis.
Organization has appointed RSO for the purpose of radiation safety monitoring and
controlling.
Radiation Safety Officer is Mr. Dipu full name
i. RSO ensures the implementation as per following documents/ practices;
a) AERB safety code no. AERB/sc/med-2 (rev. 1)
b) Radiation safety in health care guidelines
c) Gazette publication on radiation installation rules.
d) Radiological safety in health care : guidelines, Practice and outcome
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e) PNDT Act (THE PRE-NATAL DIAGNOSTIC TECHNIQUES)

f) TLD badge system for dosage monitoring and control
g) Radiation facility/ Equipment approvals as per X-ray facility/CT scan and Cath.
lab./equipment approvals AERB norms.
h) Annual examination for radiation leakages in facilities and equipments.
i) Annual x-ray and control of PPEs for damages (Lead Aprons and Thyroid sheets)
j) Display of following Sign boards is maintained as per legal requirements;

 Radiation warning sign for pregnant ladies to keep away from radiation zone.
 Radiation Hazard symbol.
 Sex Determination prohibition board (PNDT Act.)

OUTSOURCED SERVICES
The outsourced services are:
o Mammogram
o Bone Mineral Densitometry (BMD)
 MOU is established with an outsourcing agency after evaluation of the agency by a
competent person from Hospital.
 This MOU ensures the following aspects;
 Identifying a Focal person for day to day dealings from out sourcing agency
 The format for referring for tests with patient identification
 Quality Assurance Programme for outsourced services
 TAT of outsourced investigations (shall be received within 24hrs).
 Quality Assurance of outsourced centres shall be verified once in a year.
o Adherence to AERB guidelines
o Verification of Certifications and Accreditations
 This MOU is reviewed once in a year or when revision from either party takes place.
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 Requesting of Investigation will be done in hospital Request for radiological

investigation duly filled in and signed by the concerned doctor.
 In case of outpatients, Request form will be sent to the agency either through the patient
or will be mailed to the agency’s email address.
 Even though outpatients who are required to undergo the investigations are counselled to
report at the outsourced agency, it is the sole discretion of the patients / legal guardian as
to where they conduct the investigation study.
 However the reason for suggesting the outsourced agency is purely based on the Quality
assurance and as per the terms of MoU, which will be explained to the patient / legal
guardian.
 In case of inpatients, they are shifted to the outsourced facility in the hospital ambulance
accompanied by a nursing staff in case of stable patients, and by a doctor and nurse in
case of unstable patients.

RADIOLOGY QUALITY ASSURANCE PROGRAMME

i. Equipment selection is ensured to comply with AERB guidelines and approval by

competent authority nominated by AERB
ii. All imaging works are carried out after studying the patient file and doctor’s order.
iii. Patients are identified before starting the imaging by two methods;
 Wrist band
 Asking for name and correlating with patient file.

iv. Patient education is given before proceeding with the imaging

v. Patient preparation is ensured as applicable.

vi. Instrument setting and parameter setting is complied with established shooting table
in X-ray shots.

vii. Film processing and bath control is complied to standard process parameters
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viii. In case of CT scan/Ultra sound machine manufactures quality control norms are
followed.

ix. Radiation leakage test of premises and equipments shall be done minimum once in a
year by competent/ BARC approved agency.

x. CT scan equipment/X-Ray & Ultra sound equipments are calibrated for quality
parameters defined by the equipment supplier and as per corresponding standards
through annual contracts to equipment suppliers and records are maintained by Bio
Medical department.

SURVEILLANCE AND PEER REVIEW

Peer Review :

 Every month department conducts a peer review of the reports and document them for
further Quality improvement of the department.
 HOD of the department is responsible for the conduction of peer review.
 Sample size is taken on the basis of the following:
 10% of the total radiology investigations in each department
 Every 10th report of the most frequent diagnosis.
 Very rare diagnosis
 1% of clinically non-correlated diagnosis; if numbers of clinically non-correlated
findings exceeds 10% of total studies.
 Random sample of clinically non-correlated cases in case of the total non-
correlated cases is within 10% of total studies.
 Special procedures / unusual procedures done in the month
 Deviations are documented and corrective preventive actions are implemented based on
the analysis.

Surveillance
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Definition; The continuous scrutiny of factors that determines the occurrence and
distributions of diseases and other conditions of ill health. It implies watching over with great
attention, authority and often with suspicion. It requires professional analysis and
sophisticated interpretation of data leading to recommendations for control activities.

Surveillance activity;
1. Senior radiographers scrutinize the 10 % of films daily for positional error,
definition, contrast and also patient condition related errors.

2. Peer review is conducted by Consultant radiologist in 5 % cases on the process

and results on radiology test results for process errors if any.

3. Clinical correlation is done when in scan/ test procedure and appropriate

corrective actions are taken when applicable.

Note; Monthly surveillance report is prepared and submitted to Quality System Management
based on the logbook records. Quality assurance does analysis for system effectiveness.

 Radiologist in charge shall go through the diagnosis and the test requested to perform, in
case of any inappropriateness noticed for requested test, radiologist shall directly
communicate with the consultant for clarification and collaborative recommendation
shall consider for procedure.
 Annual calibration and maintenance is done through outsourcing services by Bio Medical
department and records are maintained
 Based on surveillance report where desired CA/PA are being implemented
 Equipment when do not meet the accuracy levels CA/PA are being implemented.

RADIATION SAFETY PROGRAMME

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NIMS Radiation Safety Officer (RSO) is Mr. Dipu

e-LORA registration of RSO, equipments and its details
ii. Legal compliance/ practices includes:
k) AERB safety code no. Aerb/sc/med-2 (rev. 1)
l) Gazetted publication on radiation installation rules.
m) PNDT Act (THE PRE-NATAL DIAGNOSTIC TECHNIQUES)
n) TLD badge system for dosage monitoring and control
o) Radiation facility/ Equipment approvals as per X-ray facility/CT scan and Cath.
lab./equipment approvals AERB norms.
p) Annual examination for radiation leakages in facilities and equipments.
q) Annual x-ray and control of P P Es for damages (Lead Aprons and Thyroid sheild)
r) Radiological safety in health care: guidelines, Practice and outcome
s) Display of following Sign boards is maintained as per legal requirements;

 Radiation warning sign for pregnant ladies to keep away from radiation zone.
 Radiation Hazard symbol.
 Sex Determination prohibition board (PNDT Act.)
 Caution Board warning for MRI patients and bystanders
 Red light indication in Xray and CT for intimating others that procedure is in
process.
 Restricted entry sign boards to high risk areas.
 Display on how to use TLD badges.

PERSONAL PROTECTIVE EQUIPMENTS FOR RADIOGRAPHERS

 Lead apron
 Thyroid sheild
 Gonad shield
 Gloves.
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RADIATION LEAKAGE TEST FOR LEAD APRON

xi. Radiation leakage test of premises and equipments shall be done minimum once in a
year by competent/ BARC approved agency.

xii. In-house Leakage testing of Lead aprons shall be done once in a year

xiii. To ensure a thorough inspection of the lead apron, the following types of inspections
are recommended:

i. Visual (looking at the apron)

ii. Tactile (feeling the apron for holes)

iii. Fluoroscopy / x-ray

Visual - lay the apron out on a clean, flat surface and visually inspect for any tears, perforations
or imperfections (such as bumps) that may warrant further inspection. Take note of the apron
closures (velcro, buckles, etc.) to ensure that they are in proper working order.
Tactile - run your hands over the entire surface of the apron to find any thinning of the lead or
creases. Some people prefer to lay the apron down to perform the inspection. Another method is
to hang the apron on an apron rack and place one hand on the front and one hand directly on the
back of the apron. Keeping your hands directly parallel to each other, slowly run both hands up
and down the surface area of the apron, noting anywhere there is a thinning or creasing of the
material.
X-ray - x-ray method is a suitable alternative for fluoroscopic technique
 Closely inspect each item for kinks and irregularities.
 Take a radiograph of suspect areas.
 Process the image and look for breaks in the lead lining, typically appearing as
dark slashes.
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Fluoroscopy - A fluoroscopic examination may uncover some defects overlooked in a physical

inspection. However, the disadvantage is the additional time to perform the fluoroscopic
procedures, as well as the additional radiation dose to the inspector.
 Lay out the item on the table.

 Examine the entire item using the fluoroscope’s manual settings and low
technique factors (e.g. 80 kvp).

 Shielded areas will appear dark and defects, seams, and stitching will appear
light.

 CT scan equipment/X-Ray & Ultrasound equipments are calibrated for quality

parameters defined by the equipment supplier and as per corresponding
standards through annual contracts to equipment suppliers and records are
maintained by Bio Medical department.

Radiation safety program complies to AERB guidelines as under;

i. Ref; Radiation Safety Officer Qualifications for Medical Facilities
ii. Report of AAPM Task Group 160 November 2010
iii. AERB safety code no. Aerb/sc/med-2 (rev. 1); “safety code for medical diagnostic x-ray
equipment and installations
iv. Radiologist is appointed radiation safety officer (RSO).
v. He/ She is having responsibility and authority as per office order issued based on AERB
guidelines for implementing and monitoring the radiation safety programme.

Radiation safety program is a part of the hospital wide safety manual

Radiation safety surveillance is done in safety rounds for radiation safety as well other
safety norms by the competent persons.
Radiation safety programme is also included in the periodic review by safety committee.
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Safety check list for radiation protection are followed, in case of MRI standard check list
used to eliminate errors.
For paediatric procedures, parents also allowed to accompany with safety precautions.
Informed consent is collected for all contrast procedures, moderate or deep sedation
procedures.
Radioactive material is not in the scope of the present scope of functions of the hospital.
Hazardous materials handling disposal are dealt in chapter FMS 8

Protective Barrier

The protective barrier (Three folding lead sheet) between operator/control panel and X-Ray machine
is provided complying with safety standard. (AERB radiation safety code)

Protective Lead aprons

Protective aprons are provided as per standard. (AERB radiation safety code)

their size/design shall ensure adequate protection to the torso and gonads of the radiologist
against scattered radiation.

Protective Goggles

Thyroid shield

Radiation dosage monitoring film badges;

 All radiographers and persons involving in the jobs connected with radiation hazard
including doctors are provided with radiation dosage monitoring badges;

 Monthly measurement dosages in the films of individuals is carried out by an approved

agency as per AERB guide lines

 Measurement results are reviewed by Radiation safety officer and corrective/preventive

actions are implemented as per radiation safety code.
NIMS LOGO

RADIOLOGY MANUAL DATE OF ISSUE: 01.01.2017

DATE OF LAST UPDATION:

DOC. No.: NIMS/MAN/02 01.05.2021

Area surrounding imaging lab is tested for radiation leakage by out sourced authorized
agency

Aprons/ Thyroid shields are radiographed internally to assess cracks if any which can cause
radiation leakage and records are identified.

Equipments are tested for radiation output every year through AMC by the supplier liaised
by Biomedical division.

When problem noticed corrective/preventive actions are planned and implemented.

Warning red light is provided outside the X-ray room and glows when X-ray process is on.
In all radiation facilities Radiation sticker is affixed.
Warning boards like caution for pregnancy ladies are affixed in all radiation zones as per
regulatory requirements.
DOSE LIMITS (Reproduction from standard for guidance; Always refer standard for
application)
Workers
The cumulative effective dose over a block of five years shall not exceed 100 mSv.
The effective dose in any calendar year during a five-year block shall not exceed 30 mSv.
The equivalent dose in any calendar year to the lens of the eye shall not exceed 150 mSv;
The equivalent dose in any calendar year to the skin, the hands and feet shall not exceed 500 mSv.
In case of a woman worker of reproductive age, once pregnancy has been established, the
conceptus shall be protected by applying a supplementary equivalent dose limit to the surface
of the woman's abdomen (lower trunk) of 2 mSv for the remainder of the pregnancy.
Internal exposures shall be controlled by limiting intakes of radionuclides to about 1/20 of
ALI. The employment shall be of such type that it does not carry a probability of high
accidental doses and intakes.
If expose level of radiation exceeds the limit as per above standard compulsory leave is given
to staff.
Trainees
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RADIOLOGY MANUAL DATE OF ISSUE: 01.01.2017

DATE OF LAST UPDATION:

DOC. No.: NIMS/MAN/02 01.05.2021

The effective dose in any calendar year shall not exceed 6 mSv.
Public
 The effective dose in any calendar year shall not exceed 1 mSv.
In special circumstances, a higher value of effective dose is allowed in a single year,
provided that the effective dose averaged over a five year period does not exceed 1 mSv.
TRAINING OF RADIOGRAPHERS
Training of all staff members is conducted based on the HR Training calendar
Imaging personnel are periodically trained by HOD, Radiation Safety Officer and
Incharge of Radiology department in coordination by HRM.
Orientation training is given by department incharge from time to time.
Training of the following topics are conducted to ensure quality of services.
o Department scope of services
o Management of patients (receiving, identifying)
o Documentation standards
o Positioning of patients
o Error management
o Quality assurance
o Critical alert reporting and documentation
o Surveillance and review
o Soft skill development
Radiation safety training for imaging personnel;
 As induction training for radiation workers this training is covered.
 Every year, training is repeated for all radiation workers to get refreshed.
 Training can be given by senior radiographer or Radiologist/ Radiation safety
officer.
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RADIOLOGY MANUAL DATE OF ISSUE: 01.01.2017

DATE OF LAST UPDATION:

DOC. No.: NIMS/MAN/02 01.05.2021

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