LOCAL RULES
X-RAY ROOM
G26
(South Cloisters 009)
Medical Imaging
Department
Medical Imaging, University of Exeter
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Radiography Procedures
_________________________
Radiation Safety Policy
The X-ray equipment will be used for phantom and in-vitro radiography only under
the supervision of a qualified member of staff (see list of authorised staff below).
All staff will be required to read this safety policy and the local rules and sign to
confirm this has been done.
All X-ray and associated equipment will be serviced regularly and maintained in good
order. A service contract with a specialist company will be maintained.
Three basic principles will be adhered to:
Radiography by undergraduates will only be undertaken if required for
educational purposes. Staff and postgraduate students may undertake
phantom or in-vitro work for research purposes
All exposures will be kept to a minimum (ALARP).
All exposures will be taken in such a way as to comply with current health and
safety legislation and dose limits and in particular the requirements of the
Ionising Radiations Regulations 1999.
The employer is responsible for enforcing this policy and providing local rules.
The radiation protection supervisor appointed by the employer is responsible for
enforcing the local rules and investigating overexposures and other adverse
incidents.
Local Rules to comply with the requirements of the Ionising Radiation
Regulations 1999
Radiation Protection Supervisor:
Dr Rachel M Palfrey
R.M.Palfrey@exeter.ac.uk
Medical Imaging,
Physics Building
University of Exeter,
Exeter
EX4 4QL
01392 264086
Radiation Protection Adviser: PHE - contact through URPO (Brian Robertson)
e.mail b.robertson@exeter.ac.uk tel int. 5339 or 07764959682.
Medical Imaging, University of Exeter
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Dose investigation level
Monitored doses of radiation should be very low and should not exceed 2 mSv per
annum whole body dose in one year or 0.75mSv in a single quarterly wear period.
Any doses in excess of these levels will be investigated by the radiation protection
supervisor and reported to the URPO.
Radiation Monitoring
Staff should wear the thermoluminescent dosimeter issued to them or the electronic
dosimeter provided in the X-ray room if X-ray production is expected to occur whilst
teaching. If the electronic dosimeter is used the date and time used and any dose
registered should be recorded by the wearer in the record book which is kept in the
facility.
Students should be issued with thermoluminescent dosimeters or other recognised
radiation monitoring device for use in both academic and clinical placements. These
are to be changed at the end of each clinical placement or every 4 months (IRR99).
Controlled area X-rays
The radiography room scanner area is a controlled area when any X-ray equipment
is switched on at the electrical supplies in this room, and x-ray production is enabled
by the use of the interlock key. Radiography is not carried out outside this room.
Arrangements for staff working in the controlled area
General
Entrance into controlled area
1) Only staff wearing dosimeters and external contractors whose presence the RPS
considers essential may enter the controlled areas whilst the radiography is being
carried out. Students who have read the local rules are regarded as members of
staff.
2) Persons who are under eighteen, are not normally allowed into the radiography
room when the X-ray equipment is switched on at the electricity supply, and X-ray
production is enabled due to the interlock key being in place.
3) Persons under the age of 18 years can be in the X-ray facility only in compliance
with the additional rules on page 6 of this document.
4) Staff or students who are or become pregnant are strongly advised to inform their
tutor and the radiation protection supervisor who is the employer’s representative,
in writing. The recommendation is that this is done immediately when the
pregnancy is known so that their duties may be reviewed if necessary. An
individual risk assessment should then be completed by the RPS.
5) No-one may enter the X-ray facility when an exposure is being made.
Medical Imaging, University of Exeter
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Using X-ray Equipment
1) The most senior member of staff present while an X-ray is being taken is the
radiographer or authorised staff member in charge of the X-ray procedure and
everyone else present must obey his or her instructions.
2) The exposure is selected using available guidance. This must be the minimum
necessary to obtain the required information. The light beam diaphragm must be
used for every exposure and the useful beam must be collimated to the minimum
size which still allows the required region to be examined. The main beam may
be directed downwards onto the examination table, towards the floor, the
generator wall and adjoining side walls. No horizontal beam views may be taken
where the beam is directed towards the operating console.
3) No one is to remain in the controlled area A (see facility layout) whilst the
exposure is being made.
4) In the event of the exposure switch jamming, the operator must switch the
equipment off at the mains, place a ‘Do not use’ notice on the equipment and
inform the Radiation Protection Supervisor immediately..
Reporting of Faults and overexposures
If any exposure does not terminate automatically the operator must switch off the Xray equipment at the mains electricity supply, put a large ‘Do not Use’ notice on the
equipment and inform the RPS and X-ray room co-ordinator immediately.
Any equipment failures, concerns about operating procedures or suspicions that an
over-exposure of a member of staff or anyone else has occurred, must be reported to
the RPS immediately.
Wearing of Dosimeters
1)
Dosimeters must be worn on the trunk at waist level when working in the
radiography room.
2)
Dosimeters must not be exposed to excessive heat or sunlight and Personal
dosimeters must not be left in the X-ray room.
3)
All monitored personnel must take great care of their monitor and ensure that
it is returned when it is due for change.
4)
Dosimeters must be worn beneath the lead aprons if worn.
5)
Loss or damage of dosimeters must be reported to the RPS
Medical Imaging, University of Exeter
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Duties of the Radiation Protection Supervisor
1)
The role of the RPS is to maintain proper standards of radiation protection
within the Controlled and Supervised Areas for which he/she is responsible as
set out in the Ionising Radiations Regulations 1999, the associated guidance
and these Local Rules. This includes the use of appropriate methods to
ensure that the dose received by staff and patients is as low as reasonably
practicable (ALARP).
2)
The RPS must be familiar with all radiographic procedures undertaken in the
practice.
3)
The RPS must ensure that all staff are familiar with, and follow the Local
Rules.
4)
The RPS must notify the University Radiation Protection Officer (URPO):
 If any dosimeter record shows a reading above the investigation level.
 If there is any change in practice procedures which might result in
significant increase in doses received by members of staff e.g. Increasing
utilisation of X-ray procedures, (increased numbers exposures, increased
factors)
 If there is any change in equipment e.g. new X-ray apparatus
 If maintenance work is performed on X-ray equipment which could affect
its radiation output.
 If maintenance work is performed on the structure of the X-ray room which
could affect its radiation shielding properties.
 The RPS should keep the Local Rules and Schemes of Work for the
department under constant review and when necessary revise them in
consultation with the URPO.
Summary of Arrangements for Personnel using X-ray equipment
The warning lights are illuminated automatically when the equipment is switched on
and cannot be switched on or off at any other time.
Access to the radiography room is restricted to those involved in the procedure.
If X-ray production is enabled by the use of the interlock key, an authorised member
of staff must be present. The interlock key should be stored in a locked key box
outside of use which only staff members have access to. See exception below*
*In the case of stage 3 Medical Imaging students carrying out project studies, an
authorised member of staff must be aware and available for help and advice. The
project supervisor must check the experimental set-up before students can work
independently in the X-ray room. Students must sign the form of agreement before
working independently. The interlock key should be removed from storage by a staff
member with clear guidance to students on use. Other students, regardless of stage
must be supervised whilst working in the X-ray room.
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There must be a clear educational or research benefit to be gained from the
exposure.
Personal monitoring badges must be worn by all involved in a radiographic procedure
where regular use is anticipated.
The equipment must be switched off at the mains after each session.
Additional rules for persons under the age of 18 years entering the X-ray
imaging facility
These persons;
a. Must always be under the supervision of a HCPC registered radiographer
b. Must not remain in the controlled area A or B during exposure (see facility
layout below
c. Must sign to indicate that they will obey all instructions given by the
supervising radiographer
d. Must remain in the corridor as instructed during exposure
e. Must not interfere with any equipment or items in the imaging facility
Facility layout
X-ray tube
HV Generator
Controlled Area A
Shield (lead glass)
Control Panel
Controlled Area B
Corridor
Medical Imaging, University of Exeter
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List of people Authorised to use the X-ray Equipment
Any HCPC registered Diagnostic Radiographer employed by, or seconded by the
University of Exeter
Plus:
Dr Julian Moger
Dr Judith Meakin
Dr Sharon Strawbridge
The following people have been trained in the use of the X-ray equipment and
have read the Local Rules.
See list which is kept in the X-ray room.
Signed:
Dr Rachel Palfrey
Radiation Protection Supervisor
Medical Imaging, University of Exeter
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Contingency Plan for Failure to Terminate
1. If the X-ray machine fails to terminate the radiation exposure, the operator
must press the emergency stop button or switch off the equipment at the
mains isolator.
2. The equipment must be taken out of use until the fault has been rectified.
3. The failure must be immediately reported to the RPS, URPO and X-ray
Engineer.
4. A site incident form and a radiation incident form must be completed, the latter
being passed to the URPO with a copy to the RPS.
5. If possible, the DAP meter reading or exposure time should be recorded on
the radiation incident form so that any excess exposure received by the
patient can be calculated and, if necessary, the HSE notified.
See the following risk assessment for further contingency plans.
Medical Imaging, University of Exeter
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RISK ASSESSMENT/CONTINGENCY PLAN
RISK REDUCING CONTROLS/SYSTEMS IN
PLACE
HAZARD
Accidental exposure to
radiation
- X-Ray generator interlock (key) double
locked
-physical (lead glass) barrier
-safety OFF button
- Illuminated warning lights
-Local Rules
- education and skills training
-documentary record of persons present
-personnel monitoring
- no persons permitted to remain in
Controlled Area A during exposure
- regular checks for integrity of lead
protection
LIKLIHOOD
(WITH
EXISTING
SYSTEMS IN
PLACE)
1
SEVERITY
2
RISK OF HARM TO
PERSON
PERSONS
AFFECTED
Minor risk < x1 per
year
Persons affected:
University Staff
Students
Visitors
ADDITIONAL CONTROLS
& ACTION
REQUIRED
LEVEL OF
RISK
(max25)
Removable radiation
warning sign for entrance
door
2
Open/closed radiation
source
-none identified
N/A
N/A
N/A
NONE
Chemical Hazard
-none identified
N/A
N/A
N/A
NONE
Microbiological hazard
-none identified
N/A
N/A
N/A
NONE
Fire hazard
-fire safety training (staff and students)
- fire alarm
-record of training undertaken
-electrical checks
5
Death, injury
Ongoing vigilance. Exit by
nearest suitable exit in the
event of fire.
5
Medical Imaging, University of Exeter
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Damage to equipment
Damage to PPE
-education re careful use
-regular checks for integrity of lead
protection
1
1
-Expense to
department
-Minor risk to staff
from damaged PPE
Regular Quality
Assurance programme
1
Equipment Fault /
Electrical fault
-Regular service & maintenance contract
-regular checks
1
1
-Electric shock
-Inconvenience,
-rescheduled
teaching
Maintenance of a fault log
book
2
Display screen
equipment
-regular checks
-variation in work pattern to optimise use
1
1
Eye strain, fatigue
Manual handling:
Lifting/transfer Pixie
-education re not attempting to lift unaided
2
2
Musculo-skeletal
injury
Personal injury:
Slips, trips, falls
-removable warning signs re cables, wet floor
1
3
Musculo-skeletal or
bony injury
3
Electric shock
-regular equipment checks
-safety STOP button
-circuit breakers
-warning notices
-information poster
1
5
burns, serious
injury, death
5
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1
Warning notice
4
Environmental:
Lighting
Ventilation
Noise
Temperature
-air conditioning unit
Loss or theft of valuables -Security coded lock
-high standards of integrity amongst users
Loss or theft of teaching
aids
-Security coded lock
-high standards of integrity amongst users
Psychological:
Stress, trauma
-student support services
-staff support services
Medical Imaging, University of Exeter
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1
1
Possible fumes
through air
conditioning
2
2
Users to take
sensible
precautions
1
4
1
2
Expense to the
department
2
1
2
Time off from
work/studies
2
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A separate risk assessment must be completed and regularly reviewed for those who are or might be pregnant and those who are
breastfeeding / expressing milk (see http://www.exeter.ac.uk/staff/wellbeing/safety/guidance/mothers/ ).
LIKLIHOOD
Improbable
Remote
Possible
Probable
Likely
1
2
3
4
5
SEVERITY
Very Minor
Minor
Major
Severe
Very severe
1
2
3
4
5
If Risk factor is over 5: take Remedial Action to improve Existing control measures or abandon the task
If Risk factor is 5 or under, the risks are under adequate control, but should be carefully monitored
Risks & Controls Communicated to:
Name of Risk Assessor:
users and visitors to the facility if necessary (present within a supervised area when the generator is active)
Dr R.M.Palfrey
Signature:………………………………………………………
Review Date:
January 2016
Medical Imaging, University of Exeter
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