Definition of Roles and Responsibilities for IRMER Compliance ()

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COLLEGE OF LIFE AND ENVIRONMENTAL SCIENCES
Definition of Roles and Responsibilities for Ionising Radiation (Medical
Exposure) Regulations 2000 (IRMER) Compliance
Contents
Duties of the Employer ..................................................................................................................2
Duties of the DXA Laboratory Coordinator ..................................................................................2
Duties of the Referrer ....................................................................................................................3
Duties of the Practitioner ...............................................................................................................3
Duties of the Medical Physics Expert ............................................................................................4
Duties of the Radiation Protection Adviser ...................................................................................4
Duties of the University Radiation Protection Officer ..................................................................4
Duties of the Radiation Protection Supervisor (RPS)....................................................................4
Duties of the Operator ...................................................................................................................5
Document reference: SSHS/IRMER/0002
Last update: June 2014
Review Due: June 2016
Responsible for review: Dr. Luis Gracia Marco, DXA Laboratory Coordinator, Sport and Health Sciences
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Duties of the Employer
Requirements
• Dean of College of Life and Environmental Sciences
Duties
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Correct participant identification
Pregnancy assessment of female participants of child bearing age
Identification and appointment of individuals entitled to act as referrers, practitioners and
operators
Optimisation and justification of radiation dose for standard procedures
Ensuring that written protocols exist describing how standard procedures are performed
Ensuring that quality assurance programmes for standard operating procedures are in place
Ensuring that information about referral criteria and radiation dose are available to referrers
Ensuring that a clinical evaluation of the outcome of each medical exposure is recorded
Investigation of any incidents involving overexposure and report to the Care Quality Commission
Ensuring that practitioners and operators have received adequate training
Ensuring that practitioners and operators are kept up-to-date by undertaking continuing education
Ensuring that IRMER (2000) procedures are fully complied with.
Responsibility for carrying out the above duties is delegated by the Dean of College in a formal letter
of appointment to the DXA Laboratory Coordinator.
Duties of the DXA Laboratory Coordinator
Requirements
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IRMER (2000) trained.
Experienced in the use of bone densitometry.
Academic staff member of the University of Exeter
Duties
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Duties delegated by the Dean of College and listed above under “Duties of the Employer”
Operational responsibility of the DXA laboratory.
To ensure the requirements of IRMER (2000) are met at all times.
To keep the DXA laboratory operational policies up to date in accordance with IRMER (2000)
regulations.
To ensure the procedures for initiating research projects in the DXA laboratory are followed at ALL
times (DXA operational policies and SHS specific policies).
To take control of the DXA laboratory timetable and monitor its use.
To ensure a scan request form, completed and signed by all appropriate personnel is available for
every project taking place.
To ensure every project taking place in the SHS DXA laboratory has full LREC approval.
To ensure that when scanning females of childbearing age pregnancy is assessed and recorded
according to the procedures set out in the DXA laboratory operational policies.
To take all new operators through a complete DXA induction.
To ensure QA of the DXA laboratory is regular and up to date.
To liaise with the Practitioner in the reporting of any osteopenic or osteoporotic scan result.
To ensure there are the appropriate paper trails for EVERY scan undertaken in the DXA laboratory.
To organise yearly University led continual professional development for all operators and RPS in
accordance with the requirements of IRMER (2000) and keep up to date records of any such
continual professional development.
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To ensure records of continual professional development of all operators and practitioners are
kept up to date individually.
To lead, in conjunction with practitioners and RPS, yearly DXA laboratory audits.
To undertake yearly peer review of all operators.
To convene and chair annually a DXA Laboratory User Group Meeting.
Duties of the Referrer
Requirements
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Registered medical practitioner or registered healthcare professional.
Employee of the University of Exeter or holding an Honorary Position at the University of Exeter.
Duties
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Provide the practitioner with sufficient clinical information about the participant to enable the
practitioner to justify the investigation.
Duties of the Practitioner
Requirements
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Registered medical practitioner or registered healthcare professional.
Employee of the University of Exeter or holding an Honorary Position at the University of Exeter.
Appropriate training and experience in DXA
Takes responsibility for an individual medical exposure.
Duties
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To comply with the employers procedures
Input concerning the standardisation and quality assurance of scanning procedures.
Input in the production of standard operating procedures.
Input concerning the procedures for scanning of pregnant females and those breast-feeding.
Justification of all medical exposures (sufficient net benefit).
Produce guidelines for the justification of a medical exposure that the operator should follow.
The authorisation of medical exposures (by signing the scan request form).
Make clear the individual detriment that the exposure may cause.
To ensure exposures are kept as low as reasonably practicable.
Work with the operators to ensure IRMER (2000) are enforced via audits of the DXA laboratory.
To refer participants to GP if osteopenia or osteoporosis is diagnosed.
To report overexposures, due to human error or machine fault, to the Department of Health or the
HSE if deemed necessary (if it leads to patient exposure greater than 20 times normal for the DXA
scan).
To undertake and keep records of continuing professional development.
The following duties may be delegated by the Practitioner to another individual provided that that
individual is a registered healthcare professional with appropriate experience and expertise:
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The authorisation of medical exposures (by signing the scan request form).
To refer participants to GP if osteopenia or osteoporosis is diagnosed
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Duties of the Medical Physics Expert
Requirements
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A science degree or its equivalent.
Employee of the University of Exeter or holding an Honorary Position at the University of Exeter.
Experience in the application of physics to the diagnostic and therapeutic uses of ionising radiation.
Duties
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Be available for consultation on optimisation of patient dose, operator dose and quality assurance.
To give advice on matters relating to radiation protection concerning medical exposure.
To help investigate overexposures, due to human error or machine fault, alongside the practitioner
(if it leads to patient exposure greater than 20 times normal for the DXA scan).
Aid in the development and use of new and/or complex techniques.
Duties of the Radiation Protection Adviser
Requirements
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A science degree or its equivalent.
Employee of the University of Exeter or employed by the University of Exeter in a consultative role.
Experience in the application of physics to ionising radiation.
Duties
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Advise on the radiation protection to operators and staff according to the IRR (1999).
Duties of the University Radiation Protection Officer
Requirements
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A science degree or its equivalent.
Employee of the University
Experience in the application of physics to ionising radiation.
Duties
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Advise on radiation protection to operators and staff according to the IRR (1999).
To collect and record the radiation monitoring badges of all operators and chaperones.
Duties of the Radiation Protection Supervisor (RPS)
Requirements
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A basic level of RPS recognised training
Employee of the University
Appointment as RPS by the Dean of College.
Duties
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To ensure radiation protection of Operators and chaperones according to the requirements of IRR
(1999 by ensuring compliance with the Local Rules for the DXA Laboratory.
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Ensure that DXA scanner x-ray beam emergency stop is regularly tested (once per month).
Ensure that a regular DXA scanner QA check is carried out at least once per week to confirm that
scanner is operating correctly.
Arrange annual preventative maintenance of DXA scanner, to be carried out by manufacturer’s
engineer
To collect and distribute radiation monitoring badges of all operators and chaperones.
To deal with any reported incident concerning radiation over exposure of staff and/or participants
in accordance with the DXA Laboratory Local Rules.
To deal promptly with any reported hardware problems or failsafe circuit issues reported
concerning the DXA scanner.
To oversee resetting of the DXA scanner as and when required in accordance with the DXA
operational policies.
To maintain the control log for the DXA scanner when any servicing takes place.
To arrange an annual radiation survey of the DXA Laboratory and to maintain the annual radiation
survey log.
To partake in DXA laboratory audits.
To attend an RPS refresher training course at regular intervals of no greater than 5 years .
Duties of the Operator
Requirements
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Has undertaken an IRMER (2000) training course.
Has received training in DXA scanning technique and has been assessed as competent in those
techniques.
Employee of the University
Duties
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To act at all times in accordance with IRMER (2000) requirements, the SHS DXA laboratory
operational policies and DXA Laboratory Local Rules.
To follow the justification guidelines authorised by the Practitioner when performing scans.
To undertake and record continuing professional development.

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