Radiation Management Plan
(EXAMPLE of the type of information expected. Practices are expected to
provide specific details e.g. about students/trainees and the courses that
they are undertaking. The Plan will be supported by practice protocols
and procedures, to be referenced in the plan but not submitted with it.)
For: Emma Ray
(Applicant for licence to possess/licence holder) holder of licence L/000125 to possess
of
Excel Radiology Practice
(organization)
for the practice of: Radiology
to be carried out at: 3 Atwood St, Hobart, 55 Blackwood St, Kingston, 98 Gum Avenue,
Launceston, Wattle Hospital, Perth
Plan prepared by: Randal Graph (RSO)
Date:
20/06/2006
Contact details: telephone:
facsimile:
email:
Plan accepted by Emma Ray…………………. (applicant/licence holder) who hereby
agrees to adhere to all requirements in the plan
Signature;
Date: 24/06/2006
Date for review:
24/06/2007
____________________________________________________________________________________________________________
Health Physics Branch
Phone: 03 6222 7256
Sample RMP Radiology Practice
90 Davey Street
Fax: 03 6222 7257
Issued: 30 June 2006
Hobart Tas 7000
Email: health.physics@dhhs.tas.gov.au
Review date: 30 June 2007
Page 1 of 11
Introduction:
This plan has been prepared in accordance with Regulation 8 of the
Radiation Protection Regulations 2006. The purpose of this plan is to ensure
that the practice of radiology is conducted as safely as possible and in
compliance with the Radiation Protection Act 2005 and the Radiation
Protection Regulations 2006.
Compliance with this radiation management plan will help ensure that the
radiation doses to users, other persons involved in the practice, members of
the public and the environment are below the prescribed limits and are as
low as reasonably achievable. It will also help ensure that the number of
people exposed to radiation and the likelihood of unexpected exposure to
radiation are minimised.
The plan is to be read by everyone in Excel Radiology Practice.
Information required by Regulation 8,
Radiation Protection Regulations 2006
Details of plan (Examples of
type of information expected)
(a) a brief description of the type and
scope of the radiation practice;
Radiology practice with fixed
and mobile x-ray units for
radiography and radioscopy, CT
procedures, and interventional
radiology in 10 rooms in four
premises (certificate of
registration nos. nn, mm, xx, yy).
The practice employs three
radiologists and fourteen
radiographers.
(b) a list of the radiation sources dealt
See attached details, extracted
with in the radiation practice;
from the licence document.
(c) an assessment of the potential hazards Exposure to radiation from:
from the radiation sources dealt with in
primary X-ray beam; scattered
the radiation practice;
radiation; tube head leakage.
(d) details of the environment likely to be Individual rooms in which the xexposed to radiation during the radiation ray units are located; adjacent
practice;
rooms; areas immediately
outside any external walls of
these rooms.
____________________________________________________________________________________________________________
Health Physics Branch
Phone: 03 6222 7256
Sample RMP Radiology Practice
90 Davey Street
Fax: 03 6222 7257
Issued: 30 June 2006
Hobart Tas 7000
Email: health.physics@dhhs.tas.gov.au
Review date: 30 June 2007
Page 2 of 11
(e) the radiation principles, work
practices (including quality-assurance
procedures) and equipment (including
personal radiation monitors) used to
ensure that radiation exposure of persons
or the environment is as low as is
reasonably achievable during typical
types of work carried out within the
radiation practice;
All radiology procedures taken
only if clinically justified.
Protocols for the following have
been developed and are
available:
 acceptance of referrals,
which must include clinical
reason;
 avoidance of unnecessary
radiographs;
 patient and procedure
verification;
 ensuring that each operator
is qualified to carry outa
procedure;
 ensuring that the exposure of
patients to radiation is kept
to a minimum, while
maintaining the image
quality necessary to achieve
the desired diagnostic
information sought
 avoidance of unintentional
irradiation of the
embryo/fetus;
 steps to be taken if Patient
may be Pregnant
 steps to be taken if a
Embryo/Fetus has been
Inadvertently Irradiated
 acceptance testing of X-ray
and associated equipment
 constancy testing of X-ray
and associated equipment
 QA protocol developed and
available for x-ray film
handling and developing;
 QA protocol developed and
available for digital imaging;
____________________________________________________________________________________________________________
Health Physics Branch
Phone: 03 6222 7256
Sample RMP Radiology Practice
90 Davey Street
Fax: 03 6222 7257
Issued: 30 June 2006
Hobart Tas 7000
Email: health.physics@dhhs.tas.gov.au
Review date: 30 June 2007
Page 3 of 11
Also, ensure that:
 the workload specified in the
Certificate for Registration
for each premises is not
exceeded;
 operators are trained and
authorized on licence;
 protective clothing for
operators and assistants is
provided and maintained in
good condition;
 distance/shielding
considerations are used to
minimize the dose to
operators.
 personal monitoring is
provided to and used by all
radiographers and
radiologists;
 regular analysis of repeat
radiographs is undertaken
and causes investigated
(f) details of the classes of persons likely
to be exposed to radiation during the
radiation practice, including –
(i) children; and
(ii) pregnant women; and
Neonatal and child patients and
children accompanying adult
patients
May be patients or operators of
the x-ray units. Operators may
assist with radiography but only
if they wear protective clothing,
stand at least 2 metres from xray tube and if exposure to
foetus will not exceed public
dose limit. Personal radiation
monitoring of all operators is
implemented and confirms this
requirement is met.
____________________________________________________________________________________________________________
Health Physics Branch
Phone: 03 6222 7256
Sample RMP Radiology Practice
90 Davey Street
Fax: 03 6222 7257
Issued: 30 June 2006
Hobart Tas 7000
Email: health.physics@dhhs.tas.gov.au
Review date: 30 June 2007
Page 4 of 11
(iii) volunteers in biomedical
research; and
(iv) persons exempt from section
13(1) of the Act under Part 10;
Protocols(in (e) above) have
been developed and are
implemented to protect patients
and the fetus.
Not relevant
Students in the “Bachelor of
radiography and medical
imaging” at Monash university;
radiology registrars
participating in the Diagnostic
Radiology Training Program of
the RANZCR.
Other persons: Persons
authorized on the licence to
“use” the x-ray units; theatre
staff for interventional
procedures; nursing staff in the
hospital; members of the public
who enter or are in the areas
immediately outside any of the
four premises e.g. office staff in
premises above the CT room.
____________________________________________________________________________________________________________
Health Physics Branch
Phone: 03 6222 7256
Sample RMP Radiology Practice
90 Davey Street
Fax: 03 6222 7257
Issued: 30 June 2006
Hobart Tas 7000
Email: health.physics@dhhs.tas.gov.au
Review date: 30 June 2007
Page 5 of 11
(g) the maximum dose of radiation it is
anticipated a person of a class of persons
specified in paragraph (f) will receive
while the radiation principles, work
practices and equipment referred to in
paragraph (e) are being used, and the
action to be taken if those doses are
exceeded;
Personal monitors should
indicate <250 µSv per threemonth period for all
radiographers. Interventional
radiologists should receive less
that 1 mSv in a three-month
period.
Nursing staff should receive less
than 20 µSv per four-week
period;
Theatre staff- calculations
indicate that they should receive
less than 40 µSv per four-week
period. This has been confirmed
by personal monitoring and
monitoring will continue for
four-week periods once a year.
Shielding in walls, floors and
ceilings ensures that members of
the public receive less than 20
µSv per four-week period.
Will immediately review
practices and notify DPH if
doses above these levels are
recorded.
(h) details of a course of study or training
that –
(i) is being or will be undertaken
by a person who is expected to be
dealing with a radiation source in
the radiation practice; and
(ii) requires, as part of that course
of study or training, the person to
deal with the radiation source in
the radiation practice;
(i) the name, qualifications and
experience of the supervisor of a person
referred to in paragraph (h)(i) while
undertaking that part of a course of study
“Bachelor of radiography and
medical imaging” at Monash
University. This course has a
clinical component in all four
years.
Diagnostic Radiology Training
Program of the RANZCR
Ann Limb, Gerald Trunk, senior
radiographers will supervise the
student radiographers.
____________________________________________________________________________________________________________
Health Physics Branch
Phone: 03 6222 7256
Sample RMP Radiology Practice
90 Davey Street
Fax: 03 6222 7257
Issued: 30 June 2006
Hobart Tas 7000
Email: health.physics@dhhs.tas.gov.au
Review date: 30 June 2007
Page 6 of 11
or training referred to in
paragraph (h)(ii);
(j) the training and information to be
provided to persons involved in carrying
out the radiation practice;
(k) the name and contact details of the
radiation safety officer for the radiation
practice;
(l) a brief description of the role of the
radiation safety officer;
(m) a brief description of the resources
available to the radiation safety officer to
enable him or her to perform his or her
role under the radiation management
plan;
Dr Ralph Graph, Radiologist
will supervise the radiology
registrar.
In-house radiation safety
awareness training for ALL
staff; theatre and nursing staff
assisting with radiography to
read RPS11 and licence
conditions and demonstrate an
understanding of the
requirements in these.
Randal Graph;
phone: nnn; email: nnn; fax:
nnn.
Section 5 of RPS1; attached
“duties of the RSO”.
Ensure personal monitoring
conducted appropriately and
that monitors are stored with the
controls when not in use.
Budget includes funding for
personal radiation monitoring,
QA program, replacement of
protective clothing, compliance
testing; radiation protection
training for staff.
1
National standard for limiting occupational exposure to ionizing radiation [NOHSC:1013(1995)] republished in 2002 by the chief
executive officer of ARPANSA
____________________________________________________________________________________________________________
Health Physics Branch
Phone: 03 6222 7256
Sample RMP Radiology Practice
90 Davey Street
Fax: 03 6222 7257
Issued: 30 June 2006
Hobart Tas 7000
Email: health.physics@dhhs.tas.gov.au
Review date: 30 June 2007
Page 7 of 11
(n) a description of the roles and
responsibilities, that are relevant to a
dealing with the radiation source in the
radiation practice, of all persons
authorised by the licence to deal with the
radiation source in the radiation practice;
(o) the methods used to ensure that the
persons referred to in paragraph (n) are
aware of their obligations under the Act
and the licence;
An internal document is
available that details the roles
and responsibilities of all
individuals involved in the
practice, including:
 The licence holder;
 The referrer who requests the
radiological procedure;
 The operator who performs
the irradiation of the patient;
 The practitioner responsible
for the overall conduct of the
radiological examination;
 The Radiation Safety Officer;
 The radiological equipment
suppliers;
Briefly,
RSO - see (l) above;
operators named on licence – as
per licence conditions;
all staff are responsible for
following the radiation practices
specified in this plan;
all staff must obey warning signs
and written instructions
(developed and placed in
prominent location in radiology
room/surgery) aimed at
minimizing their exposure to
radiation;
all staff are to report to the RSO
any matter that may compromise
radiation safety
Radiation safety awareness
training includes provision of
information about the licence
and its conditions.
Training program has been
developed and is available.
____________________________________________________________________________________________________________
Health Physics Branch
Phone: 03 6222 7256
Sample RMP Radiology Practice
90 Davey Street
Fax: 03 6222 7257
Issued: 30 June 2006
Hobart Tas 7000
Email: health.physics@dhhs.tas.gov.au
Review date: 30 June 2007
Page 8 of 11
(p) details of how the radiation source in
the radiation practice will be prepared for
use, repaired, maintained, transported,
stored and disposed of;
(q) details of any emergency response
plans for the radiation practice including
reporting to the Director of Public
Health;
(r) details of procedures that are designed
to minimise the radiation hazard arising
from a radiation incident;
(s) details of reporting procedures for
incidents adversely affecting, or likely to
adversely affect –
(i) equipment used in the radiation
practice; or
(ii) the environment; or
(iii) the health or safety of any
person;
Maintenance/service contracts
in place for all x-ray units;
compliance checks will be
conducted as required for each
unit;
All x-ray units will be disposed
of in accordance with the Act,
a) such that it cannot be
reassembled for use, or
b) sold or
c) traded in
when no longer required.
Protocols have been developed
and are available to deal with
incidents involving unexpected
irradiation of any person.
These include a requirement that
the DPH will be informed of any
malfunction of an X-ray unit that
could have resulted in
unexpected irradiation of any
person or of any situation where
a person could have been
exposed inadvertently and of any
incident that requires inclusion
in the Australian Radiation
Incident Register.
See protocols in (q) above.
Staff required to report any
malfunction of the x-ray
unit/observed damage to unit
(e.g. frayed cords, dents in tube
casing) to RSO immediately. Any
other incident also to be
reported to RSO who will take
immediate action and inform
Emma Ray for any further
investigation and action.
____________________________________________________________________________________________________________
Health Physics Branch
Phone: 03 6222 7256
Sample RMP Radiology Practice
90 Davey Street
Fax: 03 6222 7257
Issued: 30 June 2006
Hobart Tas 7000
Email: health.physics@dhhs.tas.gov.au
Review date: 30 June 2007
Page 9 of 11
(t) details of record-keeping requirements
including details of the records that will
be kept of movement of any mobile
radiation source in the radiation practice;
(u) details of the use of radiation warning
signs and labels in the radiation practice.
Protocol for maintenance of
records has been developed and
is available. This includes that
records of all radiographs will
be maintained for at least seven
years and will indicate the
operator, exposure factors,
patient and view. Records of
disposal of all units will be
maintained as per Regulation
26, Radiation Protection
Regulations 2006.
Warning labels on the X-ray
units and on room entrances, as
required for the certificate of
compliance.
Referenced documents:
 RPS1: National standard for limiting occupational exposure to
ionizing radiation [NOHSC:1013(1995)] republished in 2002 by the
chief executive officer of ARPANSA
 Radiation Protection Regulations 2006
 Radiation Protection Act 2005
Attached details:
 Details of x-ray units (licence schedule/application form)
 List of authorized users (licence schedule/application form)
 Duties of the RSO
____________________________________________________________________________________________________________
Health Physics Branch
Phone: 03 6222 7256
Sample RMP Radiology Practice
90 Davey Street
Fax: 03 6222 7257
Issued: 30 June 2006
Hobart Tas 7000
Email: health.physics@dhhs.tas.gov.au
Review date: 30 June 2007
Page 10 of 11
Duties of the RSO:
The RSO will:
(a) supervise the radiation protection aspects of the radiation practice
that are specified in the radiation management plan; and
(b) operate and interpret the readings from radiation monitoring
equipment that is required for the radiation practice; and
(c) understand the precautions (including the use of protective
clothing and equipment) to be taken in carrying out the radiation
practice; and
(d) understand the extent to which the precautions referred to in
paragraph (c) will restrict exposure to radiation; and
(e) know the actions required to carry out the emergency procedures
specified in the radiation management plan; and
(f) assist the holder of the licence to implement the employer’s duties
specified in Chapter 5 of the National standard for limiting
occupational exposure to ionizing radiation [NOHSC:1013(1995)]
republished in 2002 by the chief executive officer of ARPANSA; and
(g) carry out the duties specified for a radiation safety officer in the
National standard for limiting occupational exposure to ionizing
radiation.
____________________________________________________________________________________________________________
Health Physics Branch
Phone: 03 6222 7256
Sample RMP Radiology Practice
90 Davey Street
Fax: 03 6222 7257
Issued: 30 June 2006
Hobart Tas 7000
Email: health.physics@dhhs.tas.gov.au
Review date: 30 June 2007
Page 11 of 11