Audit

Previous CPA Findings

Are there any previous CPA findings?

If yes, have they been resolved?

If no, what is the status update?

Radiology

Are patient fluoro logs being kepti

Are weekly fluoroscopy checks being performed?

How are dosimetry badges being managed?

How do staff access P&Ps?

Caution X-ray signs posted?

Notice to Employees signs posted (5/09)?

Radiation Safety Operating Procedures sign posted?

Pregnancy Warning sign posted?

Lead aprons hung properly?

Lead apron checks performed annually?

Dose charts posted on all x-ray units?

Technique charts posted on all x-ray units?

Clinical Tech PM stickers posted and current?

Physician S&O permits posted & Current?

Technologists licenses posted and current?

Repeat Rate - Staff knowledge?

Any contract staff used?

Do staff know how to find MD privileges?

Nubile C-arms - MD S&O Permits?

Contrast media security

Radiation Safety Training

Crash carts?

X-ray generator affixed?

CT

CT Protocols - approved by P&T?

CT physicist report - Annual and any fails fixed?

Contrast Media documentation?

Reduced technique factors for pediatric and small patients?

Who dispenses or administers contrast media?

CT Competencies?

CT Injector Competency?

Crash Cart?

SAS 916 - CT Radiation Dose Monitoring

SB 1237

CT Table wipe down?

CT injector wipe down?

Critical Results Documentation?

Stroke Alert process?

Code Blue workflow?

MD Contrast Orders?

Contrast media security?

Dose rates posted for 8, 16, or 64 slice CT?

Medication labeling?

Contrast warmer?

Caution X-ray signs posted?

MRI

MRI Protocols approved by P&T?

Screening procedures?

MRI Safety Zones posted?

MRI Safety Training?

Code Blue process in MRI?

Are the O2 tanks non-ferrous?

MRI physicist report?

Protocols documented?

Is procedural sedation used?

MRI Tech Competencies?

MRI Tech injector Competencies?

Venipuncture (10/10)?

MRI QC

MRI Crash Cart?

MRI Safety - SAS 910

List of employees with MRI Safety Training?

List of employees with access?

MRI Safety Training?

Cleaning process for MRI Table between patients?

Is procedural sedation performed in MRI?

NM

Pregnancy warning signage?

Is I131 used?

Is there post procedure information given by the NM MD?

Who is the RSO?

Explain the radiopharmaceutical delivery process.

Microwave approved by engineering?

Microwave oven labeled "For patient use only"!

Is there a refrigerator?

NM Protocols approved by P&T?

Are medications placed in a secondary container?
Are they labeled?

Is waste storage secure?

Who has access to the Hot Lab?

Describe the process for reinjecting blood?

PPE used?

Ring & Body dosimeters used?

Is waived testing performed?

Informed consent?

Hood Inspection?

Radiation Safety Committee Meeting minutes - quorom

Radiation Detector testing and exit routes?

Radiation Safety Training?

Correct signage?

Is Regadenosn (Lexiscan) used? If yes, who administers and where is the NM MD?

Cleaning procedures foe NM table?

Posted NM contacts ICE?

Mammography

RHB Inspection status?

Physicist report?

QA program for Interpreting MDs?

Repeat Rate?

Information for breast implant patients?

IR procedures - side site verification?

QC?

Technique chart?

Dose chart?

Cleaning procedure for Mammo unit between patients?

Title 22 Informed Choice booklet for IR patients?

Mammo Tech competency?

US

Clinical tech PMs?

US equipment cleanliness?

Daily QC of Cidex?

Pre-procedure for EV probes - demonstrate.

Cleaning process for cleaning scanning table between patients?

Time-outs for IR procedures?

Side-site verification?

Secondary container labeling practice?

Title 22 Informed Choice booklet?

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.