QA of Radiation Safety Documentation

The final thing to consider in the QA programme is the quality assurance of radiation safety documentation. Schedule 2 of IRMER17 requires the employer to ensure that quality assurance programmes are followed in respect of written procedures and protocols. In this article we’ll look at what that means in practice.

Establishing a QA Programme for Procedures and Protocols

• Each employer’s procedure or protocol should be dated and given an issue number
• An issue log should be provided for each procedure or protocol, to record reviews, updates and show who the documents have been issued to – below is an example

• Procedures and protocols should be reviewed whenever there has been a change in practice, equipment or service delivery
• Routine reviews should also be undertaken, in consultation with the MPE, at least every three years

QA Procedures for Training

The Dental GNs recommend that the QA programme should include a register of all staff involved with any aspect of dental radiology and include the following information:

• Name
• Role as defined in IRMER17 (eg practitioner, referrer, operator) and details of operator duties
• Date and nature of training received, including qualifications (such as a dental degree or diploma in dental hygiene/therapy), formal training and in-house training
• Recommended date for a review of training needs

QA Audits

The quality assurance programme will require records to be made of the checks and measurements carried out. The Dental GNs recommend that the person with overall responsibility for the QA programme should:

• Check the full programme at intervals not exceeding three years to verify that the programme is being implemented effectively
• Record the corrective action taken in response to any shortcomings
• Provide for clinical audits and/or peer reviews of radiography

A clinical audit would include auditing the full QA programme and associated records; and also taking a sample cohort of patient radiographs and confirming that they had been justified, authorised and clinically evaluated in line with the employer’s procedures.

Peer review would involve an audit undertaken by one or more people with similar competencies as those involved in the work (i.e. their ‘peers’). These may be colleagues within the same, or from another, dental practice.

Below is an example of an audit form that covers the full IRMER17 QA programme as well as some of the documentation required by IRR17.