DSES is responsible for a wide range of areas of public health, including radiation protection." (Vincent, 1998)
Quality Assurance
Quality Assurance is statistically determined and tracked within each department when a radiation emitting device is in use. The Performance Improvement Team has overriding authority in this area as the specialty of that department is to ensure that all departments are removing excess waste within their process operations such that operations are statistically consistent with efficiency and effectiveness. The QA team has the acceptable and unacceptable radiation levels and will monitor the hospital to ensure there is not a breach of these levels.
The compliance department will also be in contact with the QA department to facilitate compliance reporting based on national and state standards and the current statistical information regarding the usage of radiological equipment within designated zones as well as within non-designated departments and non-designated areas. Our standards do require ensuring the level of radiation exposure to the patient, staff and visiting population remains negligible.
Equipment Testing
The Joint Commission also referred to as JCAHO renders random compliance testing every 18 months (estimated) to determine facility compliance. The radiological measure is a function of the patient safety area and is generally not tested JCAHO. However, such information is tracked by our internal safety program and is therefore subject to internal standards as well as national and state regulations. The equipment in use by our staff also must be in compliance. Compliance is measured by the ability of our radiological emitting equipment including the CT scan, the X-Ray machine, the MRI machine, and the equipment in use within the Nuclear Medicine Department.
The tests are performed by random (pull and testing) of all equipment every 6 months. The equipment is measured using radiation detecting gauges to measure radiation release, and a tag is attached to the equipment with a quality control test date, raw score, and actual radiological release information. The equipment is tested for spikes in the release of radiation as well as other malfunctioning that may cause exposure to high levels of radiation. The purpose of the test is to determine whether the equipment itself is able to maintain levels within the compliance standards. If the equipment fails to remain within one standard deviation of the threshold, it is removed from operations and replaced with a new or refurbished machine that has been tested for compliance. The acceptable range for radiation exposure is between .005 and .05 mrem
Structural Barriers in Facility Design
The facility design has incorporated a framework to limit the exposure of radiation contamination spread risk. The CT and MRI machines are located in a corridor that is on a wing designated for the containment...
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