The Annual report from the Radiation Protection Advisor provides assurance that the use of Ionising
radiations complies with statutory obligations/
An audit by the Radiation Protection Adviser was undertaken in December 2011 against the requirements
of the Ionising Radiation regulations 1999 and the Ionising Medical Exposure Regulations 2000, which
demonstrated no major areas of non-compliance.
The overall management and compliance of radiation protection was good and several areas of good
practice noted mainly staff awareness of policy and procedure.
Some opportunities for improvement in procedural and document control have been identified and are
being addressed by an action plan.
The annual report from the Radiation Protection Advisor (IRS Ltd) details the activities undertaken to meet
the requirements of the Ionising Radiation Regulations 1999 and Ionising Radiation (Medical Exposure)
Regulations 2000 for the period April 2011-March 2012.
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
Incident Reports
o Twelve incidents have been logged on Datix and reviewed in the year. Five incidents
resulted in patient x-ray doses higher than intended and have been reported to the Care
Quality Commission .Four of these reportable incidents were due to the wrong patient being
referred for examination.
Staff radiation doses
o All staff doses less than 1/10th of annual limits
o One high dose film badge readings has been investigated in the period and attributed to illfitting protective lead aprons. Garment has been replaced .

Environmental Surveys
o Survey undertaken on new gamma camera equipment installation and was satisfactory.
o The design and construction of the new hospital facilities have been surveyed and the
outstanding recommendations have been completed thus meeting all protection
requirements.
o Recommendation that further environmental monitoring be undertaken in the next 12 months
to supplement the surveys undertake at building commissioning.

Equipment
o Commissioning reports of new installed equipment (Gamma Camera and Flash pads) have
been compiled and recommendations undertaken..

Patient Doses (Diagnostic Reference levels)
o

Patient doses are within national reference ranges however on-going optimisation is required
under the IRMER legislation to continuously review and reduce patient dose.
Radioisotopes
o
Pollution Inventory completed in March 2012 with no recommendations from the
Environment Agency.
Non –Ionising radiations (Lasers/Ultrasound and Magnetic Resonance)
 Laser safety
o Self-assessment Questionnaires completed by Ophthalmology.
o Advice provided for new plastics laser service.

MRI Safety and Performance
o Communication and training to Vinci colleagues to reduce the possibility of unauthorised
access into a controlled area.
o No MRI performance issues identified.