Written procedures and protocols

It is the responsibility of the Employer to put in place written Procedures and Protocols to ensure radiation is used safely and appropriately in accordance with the Ionising Radiation (Medical Exposure) Regulations 2017 (IR(ME)R). These are an essential component of the Radiation Protection File and should be reviewed on a regular basis and updated where necessary.

Employer’s Procedures are written instructions from the Employer on how the various aspects of radiation exposure of patients will be managed and they must be complied with by all IR(ME)R duty holders (Referrers, Practitioners and Operators). The aspects of radiation exposures that the Employer’s Procedures must cover are listed in Schedule 2 of IR(ME)R [1]. A suite of example Employer’s Procedures (EP1-18; see Templates) can be downloaded from the SDCEP website and adapted to suit your practice’s needs. Alternative versions that fulfil the requirements of the regulations may be used or developed by the practice. The ‘Guidance Notes for Dental Practitioners on the Safe Use of X-ray Equipment’ [2] also provide examples of template employer’s procedures required by IR(ME)R17.

With regard to IR(ME)R, Protocols differ from Procedures in that Protocols allow the duty holder to use their professional judgment, whereas the Procedures must be followed precisely. For each x-ray machine in your practice, written Protocols are required for each type of radiographic examination, e.g. the x-ray exposure factors for a bitewing radiograph. Example Employer’s Protocols for Exposures, for different types of exposure settings (see Templates), can be downloaded from the SDCEP website and adapted to suit your practice’s needs. Other protocols identifying selection criteria for the exposures carried out in the practice (which may refer to professional guidelines, e.g. the Faculty of General Dental Practice (FGDP) ‘Selection Criteria in Dental Radiography’)[3] as well as protocols covering other processes, e.g. the operation of ancillary equipment, may also be provided by the Employer. Since these protocols will be specific to each practice, templates are not provided.

Document control is necessary to ensure that the written Procedures and Protocols are suitably authorised (by or on behalf of the Employer), regularly reviewed, and that the current versions are easily identifiable and available to the duty holders. A procedure describing how this can be done is included in the example Employer’s Procedures (see EP12).

Develop written Employer’s Procedures specific to your practice, to cover all required aspects of radiation exposures according to IR(ME)R. These may include:

Entitlement of Duty Holders: outlines the method for entitling duty holders, including the qualifications and training required for each role, and how this will be recorded (see EP1).

Referrals for Dental Exposures: to ensure that sufficient information is supplied by the Referrer to allow the patient to be correctly identified and the IR(ME)R Practitioner to justify the exposure (see EP2).

Justification and Authorisation: to ensure that any request for a radiograph is justified and authorised by an IR(ME)R Practitioner before exposure takes place (see EP3).

Patient Identification: to ensure that the correct patient is radiographed (see EP4).

Pregnancy Enquiries: to outline the practice’s approach for pregnancy enquiries prior to a dental exposure (see EP5).

Assessment of Patient Dose: to ensure that data required to assess patient dose is recorded (see EP6).

Diagnostic Reference Levels: to ensure that local DRLs are in place (see EP7).

Clinical Evaluation: to ensure that every dental exposure undertaken is clinically evaluated, with the findings documented in the patient’s notes (see EP8).

Training and Education: to ensure that duty holders have received adequate training for the duties they are entitled for, that records of training are maintained and reviewed and to ensure that duty holders undertake continuing professional development following qualification (see EP9).

Incident Reporting: to ensure that incidents and near-misses involving patient overexposures are properly investigated and recorded and, where necessary, reported to the appropriate statutory authority (see EP10).

Reducing the Probability and Magnitude of Unintentional Exposures: to minimize the probability and magnitude of accidental or unintended doses to patients (see EP11).

Document Control: to ensure that the Employer’s Procedures and Protocols are suitably authorised (by or on behalf of the Employer), regularly reviewed, and easily available to duty holders (see EP12).

Radiology Audit: defines how regular reviews of radiology practice will be carried out and recorded, for quality assurance of the processes described in the Employer’s Procedures and Protocols (see EP13).

Research Exposures: to ensure that all research undertaken restricts the dose of radiation to the minimum required to achieve the intended clinical result (see EP14).

Non-Medical Imaging: to ensure that such exposures are suitably justified and authorised (see EP15).

Exposure of Carers and Comforters: to establish appropriate dose constraints and guidance for the exposure of carers and comforters (see EP16).

Provision of Information Relating to the Benefits and Risks of an Exposure: to ensure compliance with the requirement for providing prior information on the benefits and risks associated with the radiation dose from a dental exposure (see EP17).

Equipment Inventory and Quality Assurance: to ensure that an up-to-date inventory of radiography equipment is maintained, and appropriate equipment quality assurance undertaken (see EP18).

Develop written Protocols for every type of standard radiological practice, including:

Local protocols for exposure i.e. guidelines for the exposure factors (see example Employer’s Protocols for Exposures under Templates) and selection criteria for every view taken.

Local protocols for the production and storage of radiographic images i.e. protocols for use of the processing equipment, including storage and use of developing chemicals to avoid any wasted or lost films. For digital radiography, include protocols for image production and the storage of digital images.

Ensure that the Employer’s Procedures and Protocols are regularly reviewed and subject to document control.

Ensure that all relevant staff are aware of, and follow, all written Procedures and Protocols.

Keep current versions of these written Procedures and Protocols in your Radiation Protection File.

Sources of information

Templates