Audit

Previous Findings

Are there any previous CPA findings?

If yes, have they been corrected?

If not corrected, is there a status update?

Are their previous RHB findings?

If yes, have they been corrected?

If not corrected, is there a status update?

Are there previous TJC findings?

If yes, have they been corrected?

If not corrected, is there a status update?

Documents

Is there a cone exemption policy?

Is there a P&P for CT radiation dose monitoring?

Is there a P&P for monitoring lead protective devices?

Do the CT, IR & MRI staff have injector competences?

Do all technologists who perform venipuncture have venipuncture certification?

Documentation of initial and annual competencies (CT, Amrit, & NM Techs).

Does the facility have quarterly Radiation Safety Committee meetings?

Are there minutes?

Is there a quorum?

Are all protocols (CT, MRI, NM, US) approved by P&T?

Have the department's policies and procedures been reviewed annually and approved by the MEC?

Does the department have evidence of quality improvement projects?

Can staff speak to the QI projects?

Are there any contract staff being used?

If yes, can the site provide their HR files?

If yes, is their documentation of department specific orientation?

Is there a P&P for administration of IV contrast?

Do staff follow the P&P?

Is there a P&P for MRI safety?

Is there a P&P for monitoring dosimetry badges?

Can the facility provide 12 months of dosimetry reports?

We're the reports reviewed and signed by the RSO?

Is there follow-up on any discrepancies?

Is there a tracking mechanism to ensure all badges are distributed and collected each month?

Is there documentation in the RS Mtg Minutes?

Is there a P&P for weekly fluoroscopy checks?

Can the facility provide 12 months of documentation for all fluoroscopy units?

Is each fluoroscopy unit being checked weekly?

Are the weekly log sheets current?

Are the NM JD'S approved by the MEC?

Have all JD's been approved by the MEC?

Can the facility provide two weeks (14 days, including weekends) of finalized CT reports - 2 for each day of the week?

SB1237: Does every CT report include in the body of the report the CTDIvol & DLP?

Is there a P&P for checking eyewash logs?

General Information - All Imaging Areas

Is there a valid and current PM sticker for all equipment maintained by Clinical Technology?

Are PM's performed on-time?

Are actions taken for any discrepancy on a PM or Physicist Report?

Any issues that haven't been resolved in a timely manner?

Can staff demonstrate how they access the department P&Ps?

Are mock codes routinely scheduled in all Imaging areas?

Are registry staff, including Staffing Partners, being used?

If yes, what modalities and need to review all HR files.

Are there good infection control procedures in place?

Is there a Cleaning process for cleaning x-ray table or upright stand between patients?

Is there dust on equipment?

Is linen stored properly? Title 22 70825

Have the Crash carts been checked per policy?

Are any dated supplies expired?

Are the crash carts clean?

Are the medical gas manifolds being used as hooks to hang supplies?

Are all staff and MD's wearing their ID badges with their photo ID facing outward?

Radiology

Are patient fluoro logs being kept?

Are weekly fluoroscopy checks being performed?

Are the weekly fluoro checks log sheets current?

Are the completed weekly fluoro log sheets signed after fully completed?

If there are any discrepancies, is their documentation?

Are dosimetry badges being managed?

Are occupational radiation staff, who work in areas where ionizing radiation can be generated, wearing dosimetry badges?

Can the site prove that all badges have monthly oversight?

Are staff wearing their dosimetry badges?

Are the dosimetry badges worn properly?

Caution X-ray signs posted?

Notice to Employees signs posted (5/09)?

Radiation Safety Operating Procedures sign posted?

Pregnancy Warning sign posted?

Emergency procedures posted?

X-ray generator affixed?

X-ray exposure switch affixed?

Student agreement approval letter from RHB posted?

Is the information noted on agreement followed by the site (Days of week or hours of operation, etc.)?

Lead apron checks performed prior to use and annually?

Are the lead aprons easily identified?

Are the lead skirts on fluoro towers checked prior to first use and annually?

Can staff discuss where and why portable units are stored?

Dose charts posted on all x-ray units?

Technique charts posted on all x-ray units?

Physician S&O permits posted & current?

Technologists licenses posted and current?

Is there notification as to where copies of the tech certifications and S&O permits are located and in 20 font?

Are the MD S&O Permits kept on the mobile C-arms, including the mini c-arms?

Are spacer cones affixed to all mobile c-arms?

Are the vendor's radiation safety procedures posted on each unit?

Does the mini c-arm have a label stating "For Extremity Use Only" ?

Repeat Rates - can Staff identify their or the department's overall repeat rate?

Is there any escalation process if a repeat rate is higher than acceptable?

Do staff know how to find MD privileges?

Is Contrast media secured and accessible only to authorized staff?

Is there documentation that all staff have had Radiation Safety Training?

CT

Were the current CT Protocols approved by P&T?

Are the CT techs following the most recent CT protocols approved by P&T?

Are the current CT protocols signed the Chief of the department, Section Chief, Lead Tech, and Management?

Was a CT physicist report completed annually and were any failures resolved? Is there documentation?

Are Emergency procedures posted?

Do staff know where the Emergency Stop buttons are located?

Do staff know if the Emergency Stop buttons work?

Is there Contrast Media administration documentation?

Are Reduced technique factors for pediatric and small patients in use?

Have the CT techs had their original and annual Competencies?

Does each CT tech have a vendor specific Injector Competency completed?

Has the crash Crash Cart been checked daily?

Can the CT techs discuss SAS 916 - CT Radiation Dose Monitoring?

Can the CT techs discuss SB 1237?

Can the CT techs describe the Stroke Alert process?

Can the CT techs describe the Code Blue workflow?

Is there documentation of Critical Results?

Are there MD Contrast Orders?

Is there Contrast media security?

Are injector syringes secured?

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

Is Medication labeling occurring?

Is there a blanket warmer?

Is yes, is it checked daily and following P&P?

Is there a Contrast Warmer?

Is yes, is it checked daily and following P&P?

Are Caution X-ray signs posted on all entrances to rooms with x-ray equipment?

MRI

Are there Emergency procedures?

Are they posted?

Can staff verbalize their process?

Can MRI staff describe the Code Blue process in MRI?

Were the MRI Protocols approved by P&T?

Are there MRI Safety Screening procedures?

Are all MRI Safety Zones posted?

Do all staff complete MRI Safety Training?

Is there a list of employees who completed MRI Safety Training?

Are the O2 tanks non-ferrous?

Is there a current MRI physicist report?

Are there MRI Tech Competencies, including vendor specific injector competencies?

Do the MRI techs have the correct Venipuncture (10/10) documentation?

Is there documented MRI QC?

Is the MRI Crash Cart checked daily?

Can the MRI staff discuss the MRI Safety - SAS 910 process?

Is there a List of employees with access?

Is procedural sedation performed in MRI?

IR/CCL

Are there patient fluoro logs?

Are weekly fluoro checks performed each week?

Is there a dosimetry badge P&P?

Is the dosimetry badge P&P followed?

Are the dosimetry badge reports being monitored, signed, and actions taken when there are discrepancies such as over exposures or missing badges?

Are staff and MDs wearing there dosimetry badges?

Is the control badge kept with the dosimetry badge mailing envelope?

Is there a lead apron P&P?

Are the lead aprons identified?

Are the lead aprons checked prior to use and annually?

Are the lead apron skirts on fluoro unit checked annually?

Are current S&O Permits and Tech state certifications posted?

Is there an injection competency for the IR Tech and specific to the manufacturer used?

Are time-outs used?

Are two-patient identifiers used?

Is side-site verification practiced and the area to be examined marked?

Are secondary containers labelled appropriately?

Are there contrast media orders?

NM

Is the RML current?

Are initial and annual venipuncture competencies performed on NM techs?

Is there evidence of annual live stick competencies?

Is there a Hot Lab Security plan?

Is there a P&P for stolen radiopharmaceuticals?

Are personal belongings stored in the Hot Lab or Waste areas?

Is there a Pregnancy warning sign where patients are being injected?

Is I131 used?

If yes, what post procedure information given to the patient and by whom?

Can the staff identify the RSO?

Are the NM contacts ICE posted?

Can staff explain the radiopharmaceutical delivery process?

Is the Microwave approved by engineering?

Is the Microwave oven labeled "For patient use only"!

Is the refrigerator approved by engineering?

Is the refrigerator marked for patient use only?

Is the eyewash checked routinely?

Is there a eyewash log?

NM Protocols approved by P&T?

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

Is waste storage secure?

Is access to the Hot Lab limited to authorized personnel only?

Can NM Techs describe the process for reinjecting blood?

Is PPE used?

Can staff identify where the PPE are located?

Are both Ring & Body dosimeters used?

Is waived testing performed?

Is informed consent used?

Was the Vent Hood Inspected?

For Facility a services: Are there radiation hazardous waste signs on the vent stacks from NM, including the trefoil sign?

Are there quarterlyRadiation Safety Committee Meeting minutes with a quorum?

Is there documentation of weekly Radiation Detector testing and exit routes?

Is there documentation of Radiation Safety Training?

Is there Correct RHB signage?

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

Mammography

Has the RHB Inspected Mammography for ACR accreditation?

Is there a documented QA program for Interpreting MDs?

Is there an annual Physicist report?

Can Mammo Techs discuss their Repeat Rate?

Is there state Information for breast implant patients?

Is there side site verification for Interventional procedures?

Can staff discuss Mammo QC?

Is there a Technique chart?

Can staff access department P&Ps?

Is there a Dose chart?

Is there a Cleaning procedure for Mammo unit between patients?

Does each Mammo Tech have a documented Mammo competency?

US

Does the US department clean their probes or does the SPD?

If performed by the US department, is there daily QC of the Cidex?

Can US staff accurately describe and demonstrate the probe cleaning process?

Is the Cidex temperature monitored?

Is there a Time-out for IR procedures?

Is there Side-site verification for an IR procedure?

Is there a Secondary container labeling practice?

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.