Implementing a Radiation Safety Initiative

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By Neil Singh

April 2013—Radiation safety entered the limelight after the multiple radiation overexposure incidents in California from 2008-2009. Increased media attention on patient safety requirements has helped spread radiation awareness. The general population began questioning their safety from a substance they could not see, hear, smell, taste, or touch. California was the first to regulate radiation dose from CT scans, and now Texas has done the same (effective May 1, 2013). It has been nine months since the California radiation dose safety mandate took effect (mandated July 1, 2012). Many healthcare providers outside of California may be facing a similar mandate in the future and today they are developing their own internal radiation safety programs (moving from departmental to enterprise) and are looking to California for advice.

To demystify California’s response to the mandate, initiative was taken to discuss radiation safety with one of the largest integrated delivery networks in California, Sutter Health. A Q&A session was held with Jack Dobbins, Assistant Radiology Manager at Sutter Memorial Medical Center (MMC) in Modesto, CA, who is responsible for the institution’s radiation safety measures. We discussed the organization’s reaction and response to the California Radiation Dose Safety mandate SB1237, which centered around three pillars of radiation safety:

1. Good patient care practices.

2. Minimizing litigation risks.

3. Good marketing tool to bring focus on the institution’s patient radiation safety practices.

It is imperative that a good radiation program include these three pillars in its radiation safety program foundation.

Ascendian: Describe your catalyst for initiating the dose reduction program.

JD: MMC’s catalyst in initiating a radiation safety program was not only the California radiation safety mandate, but also the desire to promote safe use of imaging medical devices, support informed clinical decision-making, and increase patient awareness on radiation safety.

Ascendian: Describe your vision, assessment, and development and delivery strategy for a dose reduction program across your organization’s people, processes, and technologic components.

JD: Our vision is to:

  • Optimize our current scanning protocols and CT dose standards;
  • Establish appropriate imaging studies for the patient based on history and prognosis;
  • Provide our physicians with the best decision making tools when ordering CT imaging procedures; and
  • Derive patient information from the RIS/PACS system (i.e patient history, weight etc.) for proper imaging planning and scanning needs, as well as storing and providing historical radiation dose information at the time of care.

Ascendian: What organizational changes and workflow transformations are being considered, required, or underway?

JD: We are currently storing all CT dose information in PACS for all patients and all exams. The organization is also looking at implementing an enterprise wide radiation dose reduction and a radiation dose monitoring software. We want to ensure we are doing our best when it comes to patient radiation safety.

Ascendian: What are your next steps or lessons learned as you move to a truly enterprise wide dose reduction program?

JD: To be successful in our enterprise wide dose reduction program, we will be conducting a VMT process to find an automated solution that will help us track radiation dose on not just CT procedures, but other modalities as well. Our goal is to increase patient safety, track radiation dose history on all patients, create efficient workflows, and be compliant.

Radiation safety will continue to gain awareness nationally. Sutter Health provides good insight on how organizations that may be facing a similar mandate or are being proactive in anticipation of one can be successful in their radiation safety initiatives. When developing your radiation safety program, keep in mind the three pillars of radiation safety, and you should have a program that increases patient safety, promotes the organization’s patient care initiatives, and minimizes litigation risks associated with radiation dose.

Neil Singh is a consultant at Ascendian Healthcare Consulting. If you have questions you can contact Neil via email

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