Table 2 Comprehensive overview on radiation protection-specific KPIs listing topics and indicators for measurements and validation
Workflow | Topic | Indicator | Definition |
|---|---|---|---|
Order | |||
Inappropriate orders CT MRI | Number of patients and % | If there is a CDS: data extraction If there is not an automatic data collection: retrospective review of 100 CT/most frequent indication (head, chest, abdomen, MSK) every year | |
Inappropriate orders done CT MRI | Number of patients and % | If there is a CDS: data extraction If there is not an automatic data collection: retrospective review of inappropriate cases (100 for head, chest, abdomen, MSK), every year | |
Procedure | |||
Computer tomography | |||
Over sampling | Number of patients | Review of 100 patients for: head, chest, abdomen, MSK every year | |
Over phasing | Number of patients | Review of 100 patients for: head, chest, abdomen, MSK every year | |
Positioning in the gantry | Number of wrong | Review of 100 patients for: head, chest, abdomen, MSK every year | |
CDRLs | % of patients beyond 75% % of patients beyond 50% | If there is a dms: data extraction every 6 months If there is not an automatic data collection: retrospective review: 100 for head, chest, abdomen, MSK, every year | |
Repeated examinations | Number of patients with more than 5 CT in a year | If there is a DMS: data extraction every 6 months If there is not an automatic data collection: retrospective review: 100 for head, chest, abdomen, MSK, every year | |
CT scan performed without contrast medium when contrast was required | Number of patients | If there is a DMS: data extraction every 6 months If there is not an automatic data collection: retrospective review: 100 for head, chest, abdomen, MSK, every year | |
Paediatric | Number of wrong protocols | If there is a DMS: data extraction every 6 months If there is not an automatic data collection: retrospective review: 100 for head, chest, abdomen, MSK, every year | |
Pregnant women | Number of misses | If there is a DMS: data extraction every 6 months If there is not an automatic data collection: retrospective review: 100 for head, chest, abdomen, MSK, every year | |
Radiography | |||
Repeated exposures | Number of repeated exposures Retrospective review: 100 for chest, msk, every year | ||
Digital radiography data deleted prior to image review | Number of patients | Review of patient examinations with data deleted every year | |
Unintended conceptus exposure | Number of misses | If there is a DMS: data extraction every 6 months If there is not an automatic data collection: retrospective review: 100 for head, chest, abdomen, MSK, every year | |
Interventional radiology | |||
Patient | Number of skin doses managed per year | ||
Patient | Threshold for deterministic effects exceeded | Review of patient cases exceeding skin dose threshold every year | |
Staff | Number of staff doses managed per year | ||
Reporting | |||
Dose reporting | % of missed | Data extraction from the RIS or from the PACS (check) | |
General | |||
Over exposure | Number of patient dose values managed per year | ||
Quality control | Number of QC per year (with written reports) and including the pacs and the patient dose management systems |