Table 3 Esperanto booklet audit topics

(1) Is there a departmental mechanism for providing patients (or their representative) with information relating to the risks/benefits associated with radiation dose from the medical exposure?

(2) Is there an established mechanism within the department to register and analyse accidental /unintended exposures?

(3) Is there a departmental policy for informing patients, or their representative, that they have undergone an accidental exposure?

(4) Is there a mechanism for record keeping and retrospective analysis of accidental or unintended medical exposures?

(5) Is there a mechanism for referring accidental exposure events to the medical physics expert (MPE) and informing the competent authority of significant events?

(6) Does the department utilise criteria, provided by the relevant radiation protection competent authority, for what constitutes an accidental or unintended significant exposure?

(7) Is there evidence for appropriate training for individuals with delegated responsibility (in the case of nonradiologists) for the justification process?

(8) Is there a departmental mechanism to confirm and document the non-pregnancy status of individuals undergoing medical exposures?

(9) Is there a written protocol for the identification of who is responsible for the justification process?

(10) For radiation exposure related to health screening by invitation on asymptomatic individuals, is there a local policy affirming justification by a competent authority?

(11) What percentage of examinations involving ionising radiation are justified in advance of being performed?

(12) What mechanism exists on the request form for contacting referrers to permit pre-exposure justification discussions to occur if necessary?

(13) Is there a written protocol for who may be responsible for justification of X-ray/fluoroscopic/ interventional ionising radiological procedures?

(14) Is there a written protocol for who may be responsible for justification of CT examinations?

(15) What mechanism is used to evaluate patient dose in high-dose procedures?

(16) What percentage of radiodiagnostic procedures have established diagnostic reference levels (DRL)?

(17) Specific technical requirements for equipment in use for medical exposures

(18) Eye lens dose limits for occupational exposure

(19) Initial education and training in radiation protection

(20) Audit of education plus training in radiation protection, doses and side effects

(21) Provision of clinical information to support justification

(22) Staff dosimetry audit – this includes a draft adapted questionnaire

(23) Evaluation of the role and responsibilities of the medical physics expert

(1) Does the radiology department record statistics about patient satisfaction?

(2) Waiting time for outpatient ultrasound appointments

(3) Protocols around radiological procedures, information in reports

(4) The practice of “routine” preoperative chest x-ray

(5) Audit of inpatient chest x-rays or abdominal x-rays

(6) What percentage of non-Ionising imaging studies (MR/Ultrasound) are consistent with the referral guidelines?

(7) Pain sensation during image-guided interventions