UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION
IMAGING POLICY AND PROCEDURE
Radiation protection for Radiology staff
Effective Date: September 1 2013 Approval: See Authorization
Supersedes Protocol: None Contact:
PURPOSE: To provide radiation protection procedures to OR staff, hospital employees, and
patients during radiology procedures.
A. All patients shall be protected to minimize exposure to radiation per exam and receive
only the amount necessary to get a diagnostic radiograph or Computed Tomography scan
B. State rules require gonadal shielding whenever it is practical and would not compromise
A. Patient Radiation Safety for Diagnostic Radiographs and CT scans
1. Radiation field is to be collimated only large enough to include anatomic part to
2. Where practical, the gonads on all patients are to be protected from scattered
radiation by the use of a gonads shield, except when the examination would be
3. Exposure factors utilized must produce minimum amount of patient exposure and
still obtain a diagnostic radiograph.
B. Employee Radiation Safety for Diagnostic Radiography
1. The x-ray beam from the x-ray tube shall not be directed toward the entrances to
2. All room entrance doors must be closed during x-ray exposures.
3. Anyone holding or monitoring a patient during an exposure (including the mini
OEC) must wear a protective lead apron or vest and skirt. Thyroid lead shields
will be available to staff.
4. Radiology personnel should stand at least six feet from the patient during
portable examination exposures whenever possible.
5. Whenever possible, the portable x-ray machine is to be between the Radiology
Technologist and the patient.
6. Employee exposure monitoring will be determined by the Hospital Radiation
D. Inspection of Personal Radiation Protection Items
1. Quality control and maintenance procedures shall be performed on a regular
schedule according to the device manufacturer’s recommendations. If analysis
shows that the system test results fall outside the device manufacturer’s
recommended limits corrective action shall be taken prior to performing patient
2. Personal radiation protection items in use will be tested by radiographic /
fluoroscopic inspection every year. If any personal radiation protection item in
use is discovered to not have been tested for more than two years, the medical
physicists responsible for oversight shall be notified by the manager or appointee.
Each employee and manager are also responsible for performing ongoing visual
inspections of personal radiation protection items and then bringing any item that
appears damaged to the attention of the managers who will, in turn, have
the medical physicists or appointee test the product.
E. Comprehensive quality assurance tests are performed on the radiographic equipment at
average annual intervals, with spot checks performed are requested, and after major repairs such
as x-ray tube replacement. These tests include measurements of image quality, radiation safety,
and overall performance of the equipment.
Kari Pulfer, R.T. (R)(CT) BS, Medical Imaging Manager
Lynn Broderick, MD Modality Chief Radiologist – Radiology, University of Wisconsin
Peter Chase, MD Modality Chief Radiologist – Radiology, University of Wisconsin
Samuel Charles, MD Medical Director Radiologist – Radiology, University of Wisconsin
Department of Radiology Community Section
John Vetter PhD ASSOC PROFESSOR (CHS) (UWSMPH) Medical Physicist, University of
AUTHORIZATION: Richard Welnick, MD, Medical Director, UWMF
Wisconsin Department of Health Services Administrative Code 157.
Medical Director Date