Chapter 2:

Radiation protection
concepts and principles
New health technologies and medical devices using ionizing radiation
have led to major improvements in the diagnosis and treatment of
human disease. However, inappropriate or unskilled use of such
technologies and devices can lead to unnecessary or unintended
exposures and potential health hazards to patients and staff. When
establishing a risk–benefit dialogue about paediatric imaging it is
important to communicate that risks can be controlled and that
benefits can be maximized by selecting an appropriate procedure and
using methods to reduce patient exposure without reducing clinical
effectiveness.
Section 2.1 presents concepts and principles of radiation protection
and discusses how they are applied to paediatric imaging.
Section 2.2 summarizes the key factors to establish and maintain a
radiation safety culture in health care to improve practice.

COMMUNICATING RADIATION RISKS IN PAEDIATRIC IMAGING – Information to support healthcare discussions about benefit and risk / 29
2. Radiation protection
concepts and principles
2.1 Appropriate use of radiation in paediatric imaging

2.1.1 Fundamentals of radiation protection in health care

2.1.1.1 Medical imaging referrers and providers

The International Basic Safety Standards for Protection against Ionizing Radiation and for
the Safety of Radiation Sources (BSS) establish specific responsibilities for health profes-
sionals related to radiation protection and safety in medical exposures (BSS, 2014). The
BSS define a health professional as “an individual who has been formally recognized through
appropriate national procedures to practice a profession related to health (e.g. medicine 1,
dentistry, chiropractic, podiatry, nursing, medical physics, medical radiation technology, 2
radiopharmacy, occupational health)”.

The BSS defines a radiological medical practitioner (RMP) as “a health professional with
specialist education and training in the medical uses of radiation, responsible for adminis-
tering a radiation dose to a patient and competent to perform independently or to oversee
procedures involving medical exposure in a given specialty” (BSS, 2014). The radiological
medical practitioner has the primary responsibility for radiation protection and safety of
patients. While some countries have formal mechanisms for accreditation, certification or
registration of RMPs, other countries have yet to adequately assess education, training and
competence on the basis of either international or national standards.

In the context of this document, the term RMP will be used to generically refer to the large
group of health professionals that may perform radiological medical procedures (i.e. as
defined in the BSS) and more specific terms will be used when/as appropriate (e.g. “radiolo-
gist 3”). The concept of a RMP primarily includes classical medical specialties using ion-
izing radiation in health care: diagnostic radiology, interventional radiology (image-guided
procedures), radiation oncology and nuclear medicine. However, in some cases, specializa-
tion of a RMP may be narrower, as with dentists, chiropractors, or podiatrists. Likewise, for
diagnostic imaging and/or image-guided procedures, cardiologists, urologists, gastroenter-
ologists, orthopaedic surgeons or neurologists may use radiology in a very specialized way.
Moreover, clinicians in some countries perform and/or interpret conventional imaging such
as chest X-rays.

1.
Including physicians as well as physicians’ assistants
2.
This includes radiographers and other radiological technologists working in diagnostic radiology, interventional
radiology and nuclear medicine
3.
In the context of this document, the term “radiologist” is used in a generic way to include diagnostic and/or
interventional radiology. In some countries diagnostic radiology and interventional radiology are established as
different disciplines, each of them with specific residency and board certification

30 / COMMUNICATING RADIATION RISKS IN PAEDIATRIC IMAGING – Information to support healthcare discussions about benefit and risk
 Chapter 2: Radiation protection concepts and principles

In the context of this document a “referrer” is a health professional who initiates the process
of referring patients to a RMP for medical imaging. For paediatric imaging in particular, the
health professionals who most often refer patients for diagnostic imaging are paediatricians,
family physicians/general practitioners. Emergency department physicians, paediatric sub-
specialists, physicians’ assistants and other paediatric health-care providers also often refer
children for paediatric imaging within their daily practice. Ultimately, any medical specialist
may need to refer paediatric patients for medical imaging and, under those circumstances,
would be considered a “referrer”. Usually, the referrer and the RMP are different people.
However, both roles are sometimes played by the same person – often deemed self-referral.
For example, dentists decide whether an X-ray exam is indicated, they interpret the images
and, in many countries, they also perform the procedure.

Medical imaging staff of a radiology department typically comprise a multidisciplinary team

which include radiologists, radiographers/radiological technologists, medical physicists and
nurses.

2.1.1.2 The principles of radiation protection in medicine

Although individual risk associated with radiation exposure from medical imaging is generally
low and the benefit substantial, the large number of individuals being exposed has become
a public health issue. Justification and optimization are the two fundamental principles of
radiation protection in medical exposures, 4 as follows:

1. Medical exposures shall be justified by weighing the expected diagnostic or therapeutic

benefits against the potential radiation detriment, with account taken of the benefits
and the risks of available alternative techniques that do not involve exposure to radia-
tion. The procedure should be judged to do more good than harm.

2. The principle of justification applies at three levels in medicine (ICRP, 2007a) as de-
scribed below:
■■ At the first level, the proper use of radiation in medicine is accepted as doing more
good than harm to society;
■■ At the second level, a specified procedure is justified for a group of patients showing
relevant symptoms, or for a group of individuals at risk for a clinical condition that
can be detected and treated; and
■■ At the third level, the application of a specified procedure to an individual patient
is justified if that particular application is judged to do more good than harm to the
individual patient.

3. The justification of a particular radiologic medical procedure is generally endorsed by

national health authorities and professional societies (e.g. to recommend a procedure
for those at risk of a particular condition). 5

4. The responsibility of justifying a procedure for a patient 6 falls upon individual profes-
sionals directly involved in the health-care delivery process (referrers, RMPs). Imaging

4.
Although the radiation protection system is based on three principles: justification, optimization and dose limi-
tation, in the case of medical exposures dose limits are not applied because they may reduce the effectiveness
of the patient’s diagnosis or treatment, thereby doing more harm than good (ICRP, 2007a)
5.
This is the “generic justification” (level 2)
6.
This is the “individual justification” (level 3)

COMMUNICATING RADIATION RISKS IN PAEDIATRIC IMAGING – Information to support healthcare discussions about benefit and risk / 31
 referral guidelines help health-care professionals make informed decisions by providing
clinical decision-making tools created from evidence-based criteria (see section 2.1.2
for more information). Justification of an exam must rely on professional evaluation of
comprehensive patient information including: relevant clinical history, prior imaging,
laboratory and treatment information.

5. When indicated and available, imaging media that do not use ionizing radiation, e.g.
ultrasonography (sound waves) or MRI (radiofrequency and electromagnetic waves) are
preferred, especially in children and in pregnant women (particularly when direct fetal
exposure may occur during abdominal/pelvic imaging). The possibility of deferring imag-
ing to a later time if/when the patient’s condition may change also must be considered.
The final decision may also be influenced by cost, expertise, availability of resources
and/or patient values.

In the context of the system of radiation protection, optimization signifies keeping doses “as
low as reasonably achievable” (ALARA). In particular for medical imaging, ALARA means de-

Box 2.1 Possible reasons for inappropriate ionizing-radiation

procedures in children
■■ Low awareness of radiation doses & associated risks ■■ Not considering or aware of more appropriate imaging
■■ Appropriateness criteria/imaging referral guidelines not modalities that do not use ionizing radiation (e.g. ultrasound
available or ignored or MRI, when available)

■■ Insufficient, incorrect or unclear clinical information ■■ Too frequent or unnecessary repeat examinations
provided for justification ■■ Pressure from referring clinicians or other specialists
■■ Lack of confidence in clinical diagnosis & over-reliance on ■■ Reliance on personal or anecdotal experience not supported
imaging by evidence-based medicine
■■ Consumer’s demand (patient’s and/or family’s expectations) ■■ Pressure to perform (e.g. quickly processing patients in the
■■ Self-referral, including requesting inappropriate additional emergency department)
imaging studies ■■ Lack of availability of alternate imaging resources-expertise
■■ Concern about malpractice litigation (defensive medicine) and/or equipment (e.g. to perform ultrasonography beyond
regular working hours)
■■ Pressure to promote and market sophisticated technology
■■ Inappropriate follow-up imaging recommendations from
■■ Lack of dialogue/consultation between referrers and imaging expert reports.
radiologists

Box 2.2 Defensive medicine: a strong driving force

The term “defensive medicine” is used to refer to a deviation ■■ 3 650 physicians surveyed between 2007 and 2008
from standard medical practice to reduce or prevent complaints ■■ 83% reported that they practiced defensive medicine
or criticism. Physicians may respond to the perceived threat
of litigation by ordering more referrals and more tests, some ■■ Their defensive clinical behaviour was related to overuse of:
of which may be recommended by clinical guidelines and • plain film X-rays: 22%
beneficial, but others might be wasteful and harmful. See below • CT scans: 33% among emergency physicians & obstetrics/
as an example a summary of the results of the Massachusetts gynaecologists and 20% in other specialties
State-wide Survey on Defensive Medicine (http://www.massmed. • laboratory tests: 18%
org/defensivemedicine/): • hospital admissions: 13%.

32 / COMMUNICATING RADIATION RISKS IN PAEDIATRIC IMAGING – Information to support healthcare discussions about benefit and risk
 Chapter 2: Radiation protection concepts and principles

livering the lowest possible dose necessary to acquire adequate diagnostic data images: best
described as “managing the radiation dose to be commensurate with the medical purpose”
(ICRP, 2007a & 2007b).

2.1.2 Justification and appropriateness of procedures

The most effective means to decrease radiation dose associated with paediatric imaging is to
reduce or preferably eliminate unnecessary or inappropriate procedures.

Justification of a procedure by the referrer and RMP (see section 2.1.1) is a key measure to
avoid unnecessary radiation dose before a patient undergoes medical imaging. Most radio-
logic investigations are justified; however, in some instances, clinical evaluation or imaging
modalities that do not use ionizing radiation could provide accurate diagnoses and eliminate
the need for X-rays. For example, although CT can be justified for investigating abdominal
pain in children, ultrasound is often more appropriate (see Figs. 10, 11 and 12).

2.1.2.1 Unnecessary procedures

Overuse of diagnostic radiation results in avoidable risks and can add to health costs. In some
countries, a substantial fraction of radiologic examinations (over 30%) are of questionable
merit and may not provide a net benefit to patient health care (Hadley, Agola & Wong, 2006;
Oikarinen et al., 2009). Boxes 2.1 and 2.2 identify some possible reasons for inappropriate
use of radiation in medical imaging.

The real magnitude of unjustified risk resulting from inappropriate use of radiation in paedi-
atric imaging remains uncertain; for example, it has been estimated that perhaps as many as
20 million adult CTs and more than one million paediatric CTs are performed unnecessarily
in the USA each year (Brenner & Hall, 2007).

Figure 10: The Royal College of Radiologists’ guidance for abdominal pain in children

Source: RCR (2012); reproduced with kind permission of The Royal College of Radiologists.

COMMUNICATING RADIATION RISKS IN PAEDIATRIC IMAGING – Information to support healthcare discussions about benefit and risk / 33
 Figure 11: The American College of Radiology’s Appropriateness Criteria® guidance for
right lower quadrant pain in children

Variant 4: Fever, leukocytosis, possible appendicitis, atypical presentation in children (less than 14 years of age)

Radiological Procedure Rating Comments RRL*

US abdomen RLQ 8 With graded compression ●
CT abdomen and pelvis with contrast May be useful following negative or equivocal ☢☢☢☢
7 US. Use of oral or rectal contrast depends on
institutional preference. Consider limited RLQ CT.
X-ray abdomen 6 May be useful in excluding free air or obstruction. ☢☢

US pelvis 5 ●
CT abdomen and pelvis without contrast Use of oral or rectal contrast depends on ☢☢☢☢
5
institutional preference. Consider limited RLQ CT.
MRI abdomen and pelvis without and with contrast See statement regarding contrast in text under ●
5
“Anticipated Exceptions”.
CT abdomen and pelvis without and with contrast Use of oral or rectal contrast depends on ☢☢☢☢
4
institutional preference. Consider limited RLQ CT.
MRI abdomen and pelvis without contrast 4 ●
X-ray contrast enema 3 ☢☢☢☢

Tc-99m WBC scan abdomen and pelvis 2 ☢☢☢☢

Rating scale: 1,2,3 Usually not appropriate; 4;5;6 May be appropriate; 7,8,9 Usually appropriate
* Relative Radiation Level

Source: ACR (2015); reproduced with kind permission of the American College of Radiologists.

Figure 12: Western Australia’s Diagnostic Imaging Pathways guidance for abdominal pain
in children

ACUTE NON-TRAUMATIC
ABDOMINAL PAIN Date reviewed: July 2014
IN CHILDREN Please note that this pathway
is subject to review and revision
Clinical assessment and
laboratory tests

The majority of patients can

be diagnosed clinically and
imaging is not required

Bilious vomiting Abdominal radiograph If distal bowel obstruction Contrast

(generally in neonates) and contrast upper suspected on abdominal enema
GI series radiograph

Suspected Abdominal radiograph Intussusception Enema Surgery

intussusception and ultrasound confirmed therapy

Normal or other Appropriate

diagnosis treatment

Suspected If high likelihood, patient If atypical for

appendicitis will often proceed to appendicitis Ultrasound
theatre without imaging

Suspected Chest
pneumonia radiograph

Suspected gynaeco-
logical condition Ultrasound

Source: Western Australian Health Department, Diagnostic Imaging Pathways; reproduced with kind permission
http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/paediatrics/acute-non-traumatic-abdo-
minal-pain#pathway.

34 / COMMUNICATING RADIATION RISKS IN PAEDIATRIC IMAGING – Information to support healthcare discussions about benefit and risk
 Chapter 2: Radiation protection concepts and principles

Duplication of imaging already performed at other health-care facilities constitutes a sig-

nificant fraction of such unnecessary examinations. To prevent this repetition, previous in-
vestigations (including images and reports) should be recorded in sufficient detail and be
available to other health-care providers i.e. at the point of care. This would help record an
individual patient’s imaging history. Methods used for tracking radiation exposure include
paper records (e.g. dose cards) as well as electronic records (smart cards and software) (Seuri
et al., 2013; Rehani et al., 2012).

2.1.2.2 Choice of the appropriate procedure

When choosing an imaging procedure utilizing ionizing radiation, the benefit–risk ratio must
be carefully considered. In addition to efficacy, safety, cost, local expertise, available re-
sources, accessibility and patient needs and values are aspects to be considered.

Adequate clinical information enables choice of the most useful procedure by the referrer and
radiologist or nuclear medicine physician. Medical imaging is useful if its outcome – either
positive or negative – influences patient care or strengthens confidence in the diagnosis; an
additional consideration is reassurance (for the patient, the family or caregivers).

2.1.2.3 Imaging referral guidelines

Faced with a clinical presentation, the referrer makes a decision based upon best medical
practice. However, complexities and rapid advances in medical imaging make it difficult for
referrers to follow changes in evidence-based standards of care. Guidance for justification of
imaging is usually provided by professional societies in conjunction with national ministries
of health.

These medical imaging referral guidelines support justification by giving evidence-based

recommendations to inform decisions by referrers and radiologists together with patients/
caregivers for the choice of appropriate investigations (Perez, 2015). The ACR Appropriate-
ness Criteria®, 7 the RCR iRefer: ”Making the best use of clinical radiology” 8 and the Western
Australian Diagnostic Imaging Pathways 9 are examples of referral guidelines (ACR, 2015;
RCR, 2012). Evidence-based imaging referral guidelines have gained widespread global ac-
ceptance. With similar prevalence for common conditions, it is not surprising to find compa-
rable guidance in different regions of the world (see Figs. 10, 11 and 12).

Imaging referral guidelines are systematically developed recommendations based upon the
best available evidence, including expert advice, designed to guide referrers in appropriate
patient management by selecting the most suitable procedure for particular clinical indica-
tions. Referral guidelines for appropriate use of imaging provide information on which par-
ticular imaging exam is most apt to yield the most informative results for a clinical condition,
and whether another lower-dose modality is equally or potentially more effective, hence more
appropriate. Such guidelines could reduce the number of exams by up to 20% (RCR, 1993
& 1994; Oakeshott, Kerry & Williams, 1994; Eccles et al., 2001).

7.
http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/RightLowerQuadrantPainSuspectedAppen-
dicitis.pdf
8.
http://www.rcr.ac.uk/content.aspx?PageID=995
9.
http://www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/paediatrics/acute-non-traumatic-
abdominal-pain#pathway

COMMUNICATING RADIATION RISKS IN PAEDIATRIC IMAGING – Information to support healthcare discussions about benefit and risk / 35
 Evidence-based referral guidelines consider effective doses, and support good medical prac-
tice by guiding appropriateness in requesting diagnostic imaging procedures. They give ge-
neric (level 2) justification, and help to inform individual (level 3) justification (see sec-
tion 1.1.3). Global evidence is used to assess the diagnostic and therapeutic impact of an
imaging exam to investigate a particular clinical indication, granting the inherent differential
diagnostic considerations.

Imaging referral guidelines are advisory rather than compulsory. Although they are not man-
datory, a referrer should have good reasons to deviate from these recommendations. Table 9
provides some examples of questions that, together with the use of imaging referral guide-
lines, may support a referrer when making a decision about the justification of a medical
imaging procedure. If in doubt, the referrer should consult an RMP. 10 Monitoring of guideline
use may be assessed with clinical audits to enhance compliance.

Table 9. Socratic questionsa for referring clinicians when considering imaging procedures

What the referrer should answer Preventable, wasteful medical

exposures to radiation
Has it been done already? Unnecessarily repeating investigations that have been
already done
Do I need it? Undertaking investigations when results are unlikely to
affect patient management
Do I need it now? Investigating too early
Is this the best investigation? Doing the wrong investigation
Have I explained the problem? Failing to provide appropriate clinical information and
questions that the imaging investigation should answer
a
Classical method to stimulate erudite thought, which has been used in radiology education (Zou et al., 2011)
Source: Adapted from RCR (2012), with kind permission of The Royal College of Radiologists.

2.1.2.4 Appropriateness and clinical decision support

Systems for improving appropriateness of imaging requests include patient care pathways
and computerized decision support implemented through clinical workflows and preferably
executed in ”real time”. For such systems to be successful, recommendations reached
through support should occur at the time and location of dynamic decision-making (Kawa-
moto et al., 2005). The integration of clinical decision support (CDS) into radiology request-
ing systems can slow down the rate of increasing CT utilization. A substantial decrease in CT
volume growth and growth rate has been reported after the implementation of CDS systems,
as shown in Fig. 13 (Sistrom et al., 2009; Sistrom et al., 2014).

Long-term studies show that integration of CDS within the radiology requesting process is
acceptable to clinicians and improves appropriateness of exam requisitions, particularly
in the emergency department (Raja et al., 2012). Apart from the technical challenges of
connectivity and interfacing with existing radiological and clinical information systems, the
limitations of CDS include behaviour that bypasses “soft stops” in the computer order entry

10.
See the glossary for the definition of this term in the context of this document. It has to be noted that it includes
not only radiologists and nuclear medicine physicians but also interventional cardiologists and any other prac-
titioners who have the responsibility of performing a radiological medical procedure

36 / COMMUNICATING RADIATION RISKS IN PAEDIATRIC IMAGING – Information to support healthcare discussions about benefit and risk
 Chapter 2: Radiation protection concepts and principles

Figure 13: Effect of the implementation of a decision support system on the growth of CT proceduresa

15000

12500

10000
CT Scans

7500

5000

2500

Decision Support Rules in Effect

0
2000-4 2001-1 2001-2 2001-3 2001-4 2002-1 2002-2 2002-3 2002-4 2003-1 2003-2 2003-3 2003-4 2004-1 2004-2 2004-3 2004-4 2005-1 2005-2 2005-3 2005-4 2006-1 2006-2 2006-3 2006-4 2007-1 2007-2 2007-3 2007-4

a
Scatterplot of outpatient CT examination volumes (y-axis) per calendar quarter (x-axis) represented by red diamonds. Appropriateness feedback
was started in qtr. 4 of 2004 and continued through the duration of the study (arrow at lower right). The solid line represents the linear compo-
nent of the piecewise regression with a break point at qtr. 4 of 2004. The dashed line shows projected linear growth without implementation of
decision support system. The dotted line and teal circles depict number of CT examinations ordered through computer order entry system.
Source: Sistrom et al. (2009); reprinted with permission

system, the inability to cover all clinical presentations and the applicability of guidance to
the individual patient. Nevertheless CDS is a useful tool to make available evidence-based
imaging referral guidance at the time of referral and has the potential to provide other rel-
evant and helpful information such as previous imaging procedures.

2.1.3 Optimization: child-size and indication-adjusted exam performance

With the development of advanced imaging techniques, imaging has become an increasingly
important component of the clinical evaluation of children. The practice of paediatric radiology
includes a number of different modalities such as conventional radiography (screen-film, com-
puted and digital radiography), fluoroscopy and computed tomography; these all use X-rays
to acquire a “picture” of anatomic structures through which radiation has passed. The latest
advances in imaging technologies provide many benefits for acquisition and post-processing
of images. Lack of understanding of these technological advances may result in unnecessary
radiation exposure; specifically, measures can often be taken to reduce the radiation dose that
children receive without adversely affecting the diagnostic benefit of the examination.

Use of adult parameters may result in greater than needed radiation exposures for children.
Exposure settings should be customized for children to deliver the lowest radiation dose nec-
essary for providing an image from which an accurate diagnosis can be gleaned, summarized
by the Image Gently campaign 11 phrase “One size does not fit all”.

11.
The Image Gently campaign is the educational and awareness campaign created by the Alliance for Radiation
Safety in Pediatric Imaging. More information available at http://imagegently.org

COMMUNICATING RADIATION RISKS IN PAEDIATRIC IMAGING – Information to support healthcare discussions about benefit and risk / 37
 2.1.3.1 Optimization of radiation protection 12 in paediatric radiology

Multiple opportunities to reduce patient dose in paediatric radiology exist. Dialogue and
collaboration among all those involved in providing health care can help to identify and take
advantage of these opportunities. Greater and more effective communication between refer-
rers and radiologic medical practitioners would facilitate the optimization process. Informa-
tion provided by the referrer (i.e. legible and clearly expressed requests) should include the
clinical questions to be addressed by the imaging procedure. This information is necessary
to determine if the procedure is justified, and it may also help to optimize the examination
protocol by adjustment of radiologic technical parameters in order to obtain image quality
adequate for particular differential diagnostic considerations, at the lowest possible radia-
tion dose (Linton & Mettler, 2003).

2.1.3.2 Conventional paediatric radiology

Conventional paediatric radiography consists of standard film-based imaging as well as com-

puted radiography (CR) and digital radiography (DR), the latter two digital technologies. CR
uses a plate which stores exposure information subsequently transferred to an image reader,
a technique often used for portable exams. A DR receptor immediately creates a post-
exposure image without the use of an intermediate storage/transfer plate. Regardless of the
modality chosen, various techniques and technologies are available to ensure that doses are
optimized and coincide with clinical purpose (ICRP, 2013b).

CR and DR offer substantial benefits compared to screen-film radiography, such as an en-

during and accessible archive (no lost films; immediate electronic availability) and image
manipulation (e.g. magnification, adjustment of contrast and brightness and greater dynamic
range that can produce adequate quality with lower exposures, which are used to produce
lighter underexposed film-based images). However, there is also a risk of unwittingly increas-
ing the patient dose, as seen in the examples explained below. Overexposed film-based im-
ages used to be dark; digital technology can compensate this overexposure by altering bright-
ness and contrast after acquisition. In addition, unless there exists a robust quality-control
programme, multiple exposures may be simply eliminated, and never make it to viewers for
interpretation (film-based technology was monitored by the use of film and the “film barrel”
where poor exposures could be monitored). In addition, manual collimation as part of post
processing can create an image sent to the viewer for interpretation that does not indicate
how much of the original picture was actually exposed (cropped out). Unfamiliarity with the
technology, such as post processing algorithms, may also decrease displayed image quality.

Education and training, as well as effective team approaches to dose management (i.e.
involving the radiologist, medical physicist and radiographer/radiological technologist) are
crucial to ensure optimization of protection in CR/DR (Uffmann & Schaefer-Prokop, 2009,
ICRP, 2007b).

2.1.3.3 Diagnostic fluoroscopy

Fluoroscopy is an imaging modality that uses an X-ray beam to produce essentially real-time
dynamic images of the body, captured by a special detector and viewed on screen. In discus-
sion with patients, families and other caregivers, a movie camera analogy is often helpful.
A plain radiography is the equivalent of a single exposure or X-ray picture while fluoroscopy

12.
Note that this document is focused on radiation protection. Other patient safety issues related to paediatric
imaging are not addressed (e.g. possible adverse effects due to contrast media)

38 / COMMUNICATING RADIATION RISKS IN PAEDIATRIC IMAGING – Information to support healthcare discussions about benefit and risk
 Chapter 2: Radiation protection concepts and principles

is an X-ray movie. With current digital technology, studies can easily be recorded onto CDs.
The possibility of displaying and recording motion during fluoroscopy renders this technique
ideal for evaluation of the gastrointestinal tract (e.g. contrast studies). Fluoroscopy is partic-
ularly helpful for guiding a variety of diagnostic and interventional procedures (see below).
Fluoroscopy can result in a relatively high patient dose, 13 however, and the total fluoroscopic
time the camera is “on” is a major factor influencing patient exposure. A number of practi-
cal measures can reduce unnecessary radiation exposure of paediatric patients in diagnostic
fluoroscopy (ICRP, 2013b).

2.1.3.4 Image-guided interventional procedures

Interventional radiology provides an opportunity to perform minimally invasive procedures

involving small medical devices such as catheters or needles, with imaging guidance provid-
ed by ultrasonography, MRI, CT or X-ray/fluoroscopy. When fluoroscopy-guided interventional
procedures are performed in children, they pose unique radiation safety issues. Fluoroscopic
doses may be relatively high and, though rarely, might result in tissue reactions (also called
“deterministic effects”) such as skin injuries, particularly in large adolescents. 14 Tissue
reactions are extremely uncommon after CT-guided procedures, however. Complex inter-
ventions may require high radiation doses and their justification has to be evaluated on a
case-by-case basis. Radiation risks can be minimized by implementing practical measures
to optimize protection (Sidhu et al., 2010; NCRP, 2011).

Before the procedure, communication between the referrer and the RMP (e.g. interventional
radiologist, interventional cardiologist, others) enables information exchange to support the
decision (justification). Other imaging options should be considered, in particular those that
do not require ionizing radiation (e.g. MRI, ultrasound). The referrer can help to collate the
patient’s past medical and imaging record to allow assessment of the patient’s cumulative
radiation exposure. Moreover, consideration of previous clinical findings may be relevant to
the current examination.

Usually, the referrer is the first health professional in the health care pathway to talk directly
to the patient and family. Communicating radiation benefits and risks of a fluoroscopy-
guided interventional procedure may deserve unique radiation safety considerations. There-
fore, the risk–benefit dialogue has to be supported by the radiological medical practitioner
(e.g. radiologist, interventional cardiologist) and other members of the radiology team (e.g.
medical physicists, radiographers/radiological technologists). This task can be facilitated
by using printed and/or electronic informational materials for physicians, patients, parents,
relatives and other caregivers. Such information may be reviewed during the informed con-
sent process and/or post-procedural directives.

During the procedure, all members of the interventional radiology team cooperate to ensure
optimization of protection and safety. Effective communication between staff helps to keep
the radiation dose as low as possible. A number of parameters that affect patient dose can

13.
Fluoroscopy, and in particular fluoroscopy-guided interventional procedures, pose particular radiation safety
issues for the staff. Doses to staff may be relatively high, and can result in adverse effects such as lens opaci-
ties. Occupational radiation protection is outside the scope of this document and further information is available
elsewhere (NCRP, 2011: IAEA radiation protection of patients website http://rpop.iaea.org/RPOP/RPoP/Content/
AdditionalResources/Training/1_TrainingMaterial/Radiology.htm).
14.
Paediatric patients vary in size from small, premature babies to large adolescents. Patient size has an influence
on the fluoroscopic dose, e.g. under automatic exposure control, tube voltage (kV) and current (mA) are both
adjusted to patient attenuation, thus resulting in a higher radiation dose in large/obese patients.

COMMUNICATING RADIATION RISKS IN PAEDIATRIC IMAGING – Information to support healthcare discussions about benefit and risk / 39
 be managed to substantially reduce the radiation dose while allowing for high-quality diag-
nostic images to guide the intervention (Miller et al., 2010).

Post-procedure information, including possible adverse effects, should be made available

to the referrer and provided to the patient and/or guardian. The referrer can keep track of
imaging history via a number of options (e.g. cards).

Clinical follow-up is indicated for patients who received relatively high skin doses during one
or more procedures. Ideally, it should be performed by the RMP rather than the referrer. But
in cases when patients live far away from the facility where the procedure was performed,
the referrer will need further information to perform the follow-up (NCRP, 2011; ICRP,
2013a). The patient and family should also be informed about clinical signs of skin injury
such as reddening of the skin (erythema) at the beam entrance site, and how to proceed if
they appear.

2.1.3.5 Computed tomography

Computed tomography is another modality which uses ionizing radiation. The patient lies on
a narrow table which moves through a circular hole in the middle of the equipment. An X-ray
beam traverses a slice of patient’s body and then travels toward a bank of detectors. Both
the X-ray source and the detectors rotate inside the machine. While the patient is moved
through the gantry inside the machine, a computer generates images of serial slices of the
body and displays the images on a monitor. Radiation dose in CT depends on several factors
and may result in a dose as high as (or even higher than) fluoroscopy.

Opportunities for reducing unnecessary radiation dose in paediatric CT include the adjust-
ment of exposure parameters to consider the child’s size (individual size/age) and the clini-
cal indication, paying attention to diagnostic reference levels or ranges (DRLs/DRRs – see
below). More details about aspects to be considered for optimization of paediatric CT have
been provided in other publications (Strauss et al., 2010; ICRP, 2013b; Strauss, Frush &
Goske, 2015).

Table 10 shows examples of the impact of adjustable CT techniques in terms of patient

radiation dose. “Child-sizing” may result in substantial reduction of the dose. Fig. 14 illus-
trates the influence of the (simulated) tube current reduction on the resulting image.

Table 10. Examples of the influence of some common adjustable CT techniques on patient radiation dose

CT Technique Influence on Radiation Dose

X-ray energy (kilovoltage peak -kVp)a Decreased kVp R decreased dose
Tube current (milliamperes-mA)a Decreased mA R decreased dose
X-ray tube rotation speed (seconds) a
Faster tube (gantry) spinning R decreased dose
Scanning range/distance (in cm) Shorter scanning distance R decreased dose
Patient position in scanner Improper positioning in gantry can increase dose
Number of scan sequences (phases) Increasing phases (e.g. pre and post contrast) increases dose
Scanning multiple body regions Minimizing scan overlap decreases dose
Optimal use of intravenous contrast (dye) Improved structure visibility may afford lower settings (e.g. kVp)
Special technologies Scanner dependent; additional dose reduction capabilities
a
Assuming all other factors are held constant. Note also that the trade-off for lower dose is often increase in image noise. Quality imaging strives
to obtain the proper balance between these factors.

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Figure 14: Influence of the assumed simulated dose reduction (e.g. added noise, no repeat scanning) on
the resulting image

a: 11-year-old child with normal appendix. (i) unadjust- b: 3-year-old child with acute appendicitis. (i) conven-
ed tube current; (ii) 50% tube current reduction; tional tube current; (ii) 50% tube current
and (iii) 75% tube current reduction. All scans show reduction; and (iii) 75% tube current reduction. Arrows
air-filled appendix (see arrows) in cross section. show thickened appendix. Note also that bowel
obstruction is readily evident in all tube current exami-
nations.

(i) (i)

(ii) (ii)

(iii) (iii)

Source: Swanick et al. (2013); reprinted with permission.

COMMUNICATING RADIATION RISKS IN PAEDIATRIC IMAGING – Information to support healthcare discussions about benefit and risk / 41
 Even for low-dose paediatric CT, protocols can be adapted to further reduce radiation doses.
A study conducted in a hospital in Belgium showed that in low-dose MDCT of the sinuses in
children, the effective dose was lowered to a level comparable to that used for conventional
radiography while retaining the adequate diagnostic quality of paranasal sinus CTs (Mulkens
et al., 2005). This study demonstrated that optimization of protocols for paranasal sinuses
CT in children can yield high-quality diagnostic images using an effective dose comparable
to that used for standard radiography. This is an example of good practice in which an effec-
tive dialogue between the referrer and the RMPs aided optimization, allowing scan protocols
to be adjusted according to clinical questions the examination was expected to answer.

2.1.3.6 Nuclear medicine

Nuclear medicine uses radioactive substances (radiopharmaceuticals) to image and mea-

sure functional aspects of the patient’s body (diagnostic nuclear medicine) and/or to de-
stroy abnormal cells (therapeutic nuclear medicine). The radiopharmaceutical accumulates
predominantly in the organ or tissue being examined, where it releases energy (radiation).
In nuclear medicine imaging this radiation is received by a detector that allows for the visu-
alization of the distribution of the radiopharmaceutical in the body. In addition to images,
radioactivity can also be measured in patient’s blood, urine and/or other samples. Thereby
it is possible to characterize and measure the function of organs, systems and tissues (e.g.
perfusion, metabolism, proliferation, receptor/antibody expression and density, etc.). The
detector most often used in nuclear medicine is the gamma camera, also called a scintil-
lation camera, either for planar (2D) or three-dimensional (3D) imaging. With the single
photon emission computed tomography (SPECT) the images are acquired at multiple angles
around the patient; computed tomographic reconstruction provides 3D information of the
distribution of the radiopharmaceutical in the patient. Nuclear medicine images can be
superimposed upon CT or MRI images, a practice called image fusion. The introduction of

Box 2.3 Ultrasonography and magnetic resonance imaging

Ultrasonography refers to the use of sound waves in medical Magnetic resonance imaging (MRI) utilizes a combination
imaging. A transducer or probe transmits sound waves and of strong magnetic fields, radio waves, and magnetic field
receives the reflected signals. Ultrasound should be considered gradients to produce 2D and 3D images of organs and internal
a viable alternative to X-rays for imaging in paediatric settings structures in the body. The high contrast sensitivity to soft
whenever possible (Riccabona, 2006). In the paediatric tissue differences and the inherent patient safety resulting
population, ultrasound frequently assesses, for example, from the use of non-ionizing radiation have been key reasons
potential cardiac abnormalities, pyloric stenosis, hip dysplasia, why MRI has supplanted CT and projection radiography for a
appendicitis, neonatal intracranial abnormalities, and both number of medical imaging procedures. For paediatric imaging,
the neonatal spine and spinal cord. Ultrasound is also used MRI is used for a variety of purposes, including the evaluation
to evaluate many other indications involving the abdomen, of diseases of the central nervous system and urinary tract,
pelvis, musculoskeletal system, thyroid and breasts as well as musculoskeletal disorders/injuries, congenital heart defects and
for vascular and endoluminal imaging. Innovative ultrasound other cardiovascular diseases (including blood vessel imaging:
approaches and new ultrasound techniques such as amplitude- MRI angiography). It can also assist in cancer staging and
coded colour Doppler, harmonic and high-resolution imaging, cancer treatment planning. MRI spectroscopy is an emerging
ultrasound contrast media and three-dimensional capability imaging technique for evaluating paediatric brain disorders.
have broadened the spectrum of indications which can be Interventional MRI entails performing interventional procedures,
evaluated by ultrasound, further establishing it as a valuable primarily involving the brain, using a specially designed MRI
imaging technique which does not require exposure to ionizing unit in an operating room. Because MRI does not use ionizing
radiation. Moreover, ultrasound-guidance is used for many radiation, it is often the examination of choice for paediatric
interventional procedures. imaging.

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positron emission tomography (PET) and integrated imaging systems (e.g. SPECT/CT, PET/
CT, PET/MRI) expanded the applications of molecular imaging with radiopharmaceuticals.

Patients undergoing PET/CT or SPECT/CT are exposed to radiation from both the injected
radiopharmaceutical and X-rays from the CT scanner. For both components the radiation
dose is kept as low as possible without compromising the quality of the examination. Most
radiopharmaceuticals used for diagnostic imaging have a short half-life (minutes to hours)
and are rapidly eliminated. Diagnostic reference levels for nuclear medicine are expressed
in terms of administered activity. To optimize protection of children and adolescents in
diagnostic nuclear medicine, dose optimization schemes for the administered activities in
paediatric patients are applied, generally based upon recommended adult dose adjusted for
different parameters such as patient’s body weight. Variations of this approach have been
recently adopted by professional societies in North America and Europe (Gelfand, Parisis &
Treves, 2011; Fahey, Treves & Adelstein, 2011; Lassmann et al., 2007; Lassmann et al.,
2008; Lassmann et al., 2014). The ultimate goal is to reduce radiation exposure to the low-
est possible levels without compromising diagnostic quality of the images.

2.1.3.7 Dental radiology

Intra-oral “bite-wing” X-rays and/or panoramic radiography are longstanding tools of den-
tists and orthodontists, but present availability of cone-beam CT (CBCT) and multi-slice CT
(MSCT) to assess dentition and/or oral-maxillofacial pathology raises questions of justifica-
tion and optimization. The SEDENTEXCT Panel 15 concluded in 2011 that there is a need for
research demonstrating changed (and improved) outcomes for patients before widespread
use of CBCT for this purpose could be considered. An exception to this would be where
current practice is to use MSCT for localization of unerupted teeth (Alqerban et al., 2009).
In such cases, CBCT is likely to be preferred over MSCT if dose is lower. In any case, ra-
diological examination of maxillary canines is not usually necessary before 10 years of age
(European Commission, 2012).

The utilization of ultrasonography and magnetic resonance imaging in children has increased
over the past several years. These modalities use non-ionizing radiation to generate images.
Although this document is focused on ionizing radiation risk communication, general infor-
mation about those procedures is provided in Box 2.3.

2.1.3.8 Diagnostic reference levels

Diagnostic reference levels (DRLs) are a form of investigation levels of dose (in diagnostic
and interventional radiology) or administered radioactivity (in nuclear medicine), defined
for typical examinations and groups of standard-sized patients as tools for optimization and
quality assurance. Size variation of adults is small compared to the range of size variation
in paediatric patients. Therefore, specific DRLs for different sizes of children are needed
in paediatric imaging. These are generally specified in terms of weight or age. DRLs do not
limit dose; they are advisory rather than compulsory, although implementation of the DRL
concept is a basic safety standard requirement. Once established, DRLs are periodically re-
viewed and updated to reflect benchmarks consistent with current professional knowledge.
Facilities can compare doses in their practices with DRLs for suitable reference groups of

15.
The SEDENTEXCT project (2008–2011) was supported by The Seventh Framework Programme of the European
Atomic Energy Community (Euratom) for nuclear research and training activities (2007–2011), http://cordis.
europa.eu/fp7/euratom/

COMMUNICATING RADIATION RISKS IN PAEDIATRIC IMAGING – Information to support healthcare discussions about benefit and risk / 43
 patients to ensure that doses for a given procedure do not deviate significantly from those
delivered at peer departments. DRLs help identify situations where the patient dose or ad-
ministered activity is unusually high or low (ICRP, 2001 & 2007b).

2.1.3.9 Reducing repeat examinations and tracking radiation history in paediatric patients

One third of all children having CT scans have been reported to have three or more CT scans
(Mettler et al., 2000). Individual patient radiation dose through repeated procedures may
fall to within the range of a few tens of mSv of effective dose or may even exceed 100 mSv
(Rehani & Frush, 2011). Repeated X-rays examinations are often performed for prematurely
born children as well as for babies with hip dysplasia (Smans et al., 2008). Paediatric pa-
tients with chronic diseases (e.g. congenital heart disease, cancer survivors) may undergo
multiple imaging and interventional procedures. They may therefore have relatively high
cumulative exposures. In such patients non-ionizing imaging modalities such as MRI or
ultrasound should be considered viable alternatives whenever possible (Seuri et al., 2013;
Riccabona, 2006).

Paediatricians and family physicians can promote methods for tracking radiation exposure
histories of their paediatric patients. A number of options have been proposed (e.g. e-health
records, electronic cards, radiation exposure records integrated within e-health systems,
web-based personal records, radiation passport, and paper cards). The Image Gently website
provides a downloadable form entitled “My Child’s Medical Imaging Record”, 16 similar to
immunization cards.

For relatively low-dose procedures (e.g. chest X-ray, other conventional X-ray procedures) a
reasonable approach would be to track just the number of exams. However, for procedures that
deliver higher doses (e.g. CT, PET/CT, image-guided interventional procedures, most nuclear
medicine procedures) it is advisable to record the dose per exam (or factors that might allow a
dose estimate) in addition to the number of those exams (Rehani & Frush, 2010).

2.2 Promoting a radiation safety culture to improve practice

2.2.1 What is radiation safety culture in health-care settings?

The ultimate goal of radiation protection in health care is the safety of patients and others, 17
by minimizing the risks associated with the use of radiation while maximizing benefits for
patients’ care.

Health-care delivery contains a certain degree of inherent risk. As health-care systems and
processes become more complex and fragmented, the risk at each point of care and the
number of points of care may increase. The success of treatment and the quality of care do
not depend on the competence of individual health-care providers alone. A variety of other
factors are important. These include organizational design, culture and governance as well
as the policies and procedures intended to minimize or mitigate the risks of harm.

16.
Available at http://www.imagegently.org/Portals/6/Parents/Dose_Record_8.5x11_fold.pdf
17.
In this context “others” refers to parents/caregivers, health workers and the general public

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Health-care institutions are increasingly aware of the importance of transforming their orga-
nizational culture to improve the protection of patients and health-care workers. European
data consistently show that medical errors and health-care related adverse events occur in
8% to 12% of hospitalizations. 18 Health-care facilities should be accountable for continu-
ally improving patient safety and service quality.

Organizational culture is typically described as a set of shared beliefs among a group of in-
dividuals in an organization. Safety culture is a part of the organizational culture that can be
defined as the product of individual and group values, attitudes, perceptions, competencies
and patterns of behaviour that determine the commitment to, and the style and proficiency
of an organization’s safety management. Three main developmental stages of the safety
culture have been identified:
■■ Stage 1: Basic compliance system – All safety training programmes, work conditions,
procedures and processes comply with regulations. This is passive compliance.
■■ Stage 2: Self-directed safety compliance system – workers ensure regulatory compli-
ance and take personal responsibility for training and other regulatory provisions. This
emphasizes active compliance with the regulations.
■■ Stage 3: Behavioural safety system – teaching individuals to scan for hazards, to fo-
cus on potential injuries and the safe behaviour(s) that can prevent them, and to act
safely. This emphasizes inter-dependence among the workforce, i.e. looking after each
other’s safety. The objective of any culture development programme is to move the
organizational and individual behaviours towards the highest stage.

In this context, patient safety culture comprises shared attitudes, values and norms related
to patient safety.

Radiation safety culture in health care considers radiation protection of patients, health
workers and the general public. It is embedded in the broader concept of patient safety and
is included in the concept of good medical practice. Therefore, it uses the same approaches
that are used to implement safety culture in health-care settings (e.g. no blame, no shame,
willingness, team work, transparent communication, error reporting for learning). 19

Radiation safety culture in medical imaging enables health-care providers to deliver safer
and more effective health care tailored to patients’ needs. It is mainly addressed to ensuring
the justification/appropriateness of the procedure and the optimization of the protection,
keeping in mind that primary prevention of adverse events will always be a major objective.

Radiation protection is an important element of overall patient safety. Equipment issues,

process failures, and human errors in care delivery can jeopardize patient safety. Patient
safety is an inseparable component of professional responsibility in health care (Lonelly et
al., 2009).

Leadership is a key component of radiation safety culture. Building a safety culture requires
leadership and support from the highest level in the organization. Leaders dedicated to im-
proving patient safety can significantly help to build and sustain a stronger radiation protec-

18.
From the website of WHO’s European Region on patient safety: http://www.euro.who.int/en/health-topics/Health-
systems/patient-safety/data-and-statistics
19.
More information at the following links:
http://www.euro.who.int/en/what-we-do/health-topics/Health-systems/patient-safety/facts-and-figures;
http://healthland.time.com/2013/04/24/diagnostic-errors-are-more-common-and-harmful-for-patients/;
and http://www.oecd.org/health/ministerial/forumonthequalityofcare.htm

COMMUNICATING RADIATION RISKS IN PAEDIATRIC IMAGING – Information to support healthcare discussions about benefit and risk / 45
 tion culture in medical imaging. All stakeholders in health-care pathways involving use of
radiation for medical imaging have a role to play: radiologists, nuclear medicine physicians,
radiographers/radiological technologists, medical physicists, referrers, nurses, support staff
members and business administrators. In addition, patients, patient networks and organiza-
tions contribute to the successful implementation of a radiation protection culture. They
are natural partners to collaborate in the development and promotion of a safety culture, by
facilitating a constructive dialogue and advocating for patient-centred care.

2.2.2 Radiation safety and clinical governance

Clinical governance has been defined as “a framework through which organisations are
accountable for continually improving the quality of their services and safeguarding high
standards of care by creating an environment in which excellence in clinical care will flour-
ish” (Scally & Donaldson, 1998). The principles of quality of health care services include
safety, effectiveness, patient-centredness, timeliness, efficiency, affordability and equality
(WHO, 2006; Lau & Ng, 2014; WHO 2015b). The concept of clinical governance should
include radiation protection, to provide the corporate responsibility required to establish and
maintain a radiation safety culture.

Four pillars of clinical governance have been proposed, and radiation safety is implicit in all
of them as shown in the examples below:
■■ Clinical effectiveness is generically defined as a measure of the extent to which a
clinical intervention works. In medical imaging this is linked to the appropriateness of
procedures, which can be enhanced by the implementation of evidence-based clinical
imaging guidelines.
■■ Clinical audit is a way to measure the quality of health care, to compare performance
against standards and to identify opportunities for improvement. In radiology services
it includes auditing the implementation of the justification and optimization prin-
ciples. Clinical audit provides the evidence for changes in resource allocation.
■■ Risk management strategies in radiology services aim to identify what can go wrong,
encourage reporting and learning from adverse events, prevent their recurrence and
implement safety standards to enhance radiation protection.

Box 2.4 Steps to establish and maintain radiation safety culture

(a) Promote individual and collective commitment to protection (e) Ensure accountability of the organization and of individuals
and safety at all levels of the organization at all levels for protection and safety
(b) Ensure a common understanding of the key aspects of (f) Encourage open communication with regard to protection
safety culture within the organization and safety within the organization and with relevant parties,
(c) Provide the means by which the organization supports as appropriate
individuals and teams in carrying out their tasks safely and (g) Encourage a questioning and learning attitude and
successfully, with account taken of the interactions between discourage complacency with regard to protection and safety
individuals, technology and the organization (h) Provide the means by which the organization continually
(d) Encourage the participation of workers and their seeks to develop and strengthen its safety culture.
representatives and other relevant persons in the Source: Adapted from BSS (2014), with permission from IAEA
development and implementation of policies, rules and
procedures dealing with protection and safety

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 Chapter 2: Radiation protection concepts and principles

■■ Education, training and continuing professional development (i.e. life-long learning)

is essential to improve safety and quality in the medical uses of ionizing radiation.

2.2.3 Establishing a radiation safety culture

Establishing a radiation safety culture must start from the top of the organization but the
dimensions and promotion of the culture will rely on ownership by all of the relevant stake-
holders involved in provision of the service, including directors, administrators, health-care
providers, other support staff, patients and families.

Radiation safety culture can be established, maintained and improved by implementing a

number of possible interventions as described in Box 2.4 (BSS, 2014) and Table 11 (Eccles
et al., 2001; Michie & Johnston, 2004).

Table 11. Strategies to improve radiation safety culture

Elements effecting the culture Strategies to improve radiation Examples

safety culture
Basic underlying assumptions Education, advocacy (i.e. raising Radiation protection education in
awareness) medical and dental schools, campaigns
Adopted shared values Standards, norms, guidelines Radiation basic safety standards, referral
guidelines for medical imaging
Artefacts/visible products Training, audit, feedback and quality On-the-job training, operational rounds,
improvement behavioural change through targeted
messages

Reporting and learning systems can enhance patient safety by contributing to learning from
adverse events and near misses in the health-care system. These systems should lead to
a constructive response based on analysis of risk profiles and dissemination of lessons for
preventing similar events, an important component of primary prevention.

Organizations with a positive radiation safety culture are characterized by communications

founded on mutual trust, shared perceptions of the importance of radiation protection and
safety, and by a commitment to the development and implementation of effective radiation
protection measures. Effective communication has been emphasized as key for improving
patient safety and is essential to establish and maintain radiation safety culture in medical
settings. Health-care providers need to develop skills and self-assurance to feel comfortable
speaking out in situations of uncertainty, regardless of their position in the medical and/or
organizational hierarchy, and the position of the others involved in the situation. Effective
health-care delivery systems rely heavily on high degrees of skill in communication. This in-
cludes communication about the results and actions of issues identified. Operational rounds
at the site of imaging are helpful to discuss front-line employees’ concerns about patient
safety, quality of care and patient and family satisfaction (Lonelly et al., 2008).

As with other safety checklists in health care, radiation safety checklists that are based on
scientific evidence are risk management tools. Their proper use is a component of a radia-
tion safety culture. While standardization is the basis for any safety checklist, all checklists
need to be continually assessed and updated as necessary to ensure that they are still ac-
complishing their goals.

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 Through clinical audit, medical procedures including medical imaging are systematically
reviewed against agreed standards for good medical practice. Clinical audit also requires
the application of new standards where necessary and appropriate. This aims to improve
the quality and the outcome of patient care, thus also contributing to improving radiation
safety culture.

Teamwork contributes to enhance patient safety (Baker et al., 2005; Baker et al., 2006).
Organizations should make patient safety a priority by establishing interdisciplinary team
training programmes that incorporate proven methods for team management. Team mem-
bers must possess specific knowledge, skills, and attitudes that can be elicited and assessed
throughout a worker’s career. A report from the Department of Health in the United Kingdom
of Great Britain and Northern Ireland examines the key factors at work in organizational
failure and learning. The report identifies four key areas that must be developed in order to
move forward:
■■ unified mechanisms for reporting and analysis when things go wrong;

■■ a more open culture, in which errors or service failures can be reported and discussed;

■■ mechanisms for ensuring that, where lessons are identified, the necessary changes are
put into practice;
■■ a much wider appreciation of the value of the system approach in preventing, analys-
ing and learning from errors.

The report concludes the discussion with a critical point: “With hindsight, it is easy to see
a disaster waiting to happen. We need to develop the capability to achieve the much more
difficult – to spot one coming” (NHS, 2000).

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