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TRW.H&S.SOP.1278.1 Radiation Safety Training Procedure under the Ionising Radiations Medical
Trust Standard Operating Procedure
Radiation Safety Training Procedure under the Ionising Radiations
Medical Exposures Regulations 2017 (IRMER 2017)
Issue Date Review Date Version May 2020 May 20 25 1
Purpose
This document outlines the mandatory training required for all staff who are acting as duty
holders under IRMER 2017. It includes guidance on where the training can be accessed
and how often it should be completed. It does not concern training in relation to the safety
of staff.
Who should read this document?
Employer, Line Manager(s), Service Lines; Duty Holders
Key Messages
This procedure reflects the legal requirements of the Ionising Radiations Medical Exposure
Regulations 2017 and the associated DOH Guidance to the Ionising Radiation (Medical
Exposure) Regulations 2017 published June 2018. Adherence to this procedure will ensure
compliance with these regulations with regard to the training of personnel acting as Duty
Holders within University Hospitals Plymouth NHS Trust.
Where staff are concurrently employed providing services to another employer in a similar
duty holder role they will require entitlement by that employer under that employer’s IRMER
written procedures and that employer will need to keep concurrent training records.
If staff are employed via a second party such as an agency they require entitlement by the
employer they are contracted to, but the agency remain responsible for keeping up to date
the training records for that duty holder.
TRW.H&S.SOP.1278.1 Radiation Safety Training Procedure under the Ionising Radiations Medical
Core accountabilities
Owner Clinical and Radiation Physics
Review (^) Radiation Safety Committee
Ratification (^) Director of Healthcare Science & Technology (Peter Wright)
Dissemination (Raising Awareness)
Radiation Safety Committee
Compliance (^) Radiation Safety Committee
Links to other policies and procedures
IRMER Written Procedures for Oncology IRMER Written Procedures for Imaging IRMER Written Procedures for Cardiology IRMER Written Procedures for Nuclear Medicine IRMER Written Procedures for Surgery IRMER Written Procedures for Breast Services IRMER Written Procedures for Bone Densitometry
Version History
1 May 2020 Final Version
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An electronic version of this document is available on Trust Documents.
Larger text, Braille and Audio versions can be made available upon
request.
TRW.H&S.SOP.1278.1 Radiation Safety Training Procedure under the Ionising Radiations Medical
Standard Operating Procedure (SOP)
Ionising Radiation Medical Exposures Training
1 Introduction
The employer has a responsibility to ensure that all staff who are entitled to work as IRMER practitioners and operators, regards medical and non- medical exposures, are adequately trained within the scope of their practice. Adequate training is that which satisfies the requirement in Schedule 3 of IRMER17.
Regulation 17 of the IRMER States:
(1) Subject to the following provisions of this regulation a practitioner or operator must not carry out any exposure or any practical aspect without having been adequately trained.
(2) A certificate issued by an institute or person competent to award degrees or diplomas or to provide other evidence of adequate training is, if such certificate so attests, sufficient proof that the person to whom it has been issued has been adequately trained.
(3) Nothing in paragraph (1) above prevents a person from participating in practical aspects of the procedure as part of practical training if this is done under the supervision of a person who is adequately trained.
(4) The employer must keep and have available for inspection by the relevant enforcing authority an up-to-date record of all relevant training undertaken by all practitioners and operators engaged by the employer to carry out any exposures or any practical aspect of such exposures showing the date or dates on which training qualifying as adequate training was completed and the nature of the training.
(5) Where the employer (“employer A”) enters into a contract with another employer (“employer B”) to engage a practitioner or operator otherwise employed by that employer B, employer B is responsible for keeping the records required by paragraph (4) and must supply such records to employer A immediately upon request.
(6) Schedule 3 makes further provision about the training of practitioners and operators.
2 Definitions: IRMER Reg. 2
2.1 The term “medical exposure’ means an exposure:
(a) to patients as part of their own medical diagnosis or treatment;
(b) to individuals as part of health screening programmes;
(c) to patients or other persons voluntarily participating in medical or biomedical, diagnostic
or therapeutic, research programmes;
(d) to carers and comforters;
TRW.H&S.SOP.1278.1 Radiation Safety Training Procedure under the Ionising Radiations Medical
(e) to asymptomatic individuals;
2.2 The term “non-medical exposure” means an exposure to individuals undergoing non-medical imaging using medical radiological equipment.
2.3 The term “Medical Physics Expert” (MPE) means an individual or a group of individuals, having the knowledge, training and experience to act or give advice on matters relating to radiation physics applied to exposure, whose competence in this respect is recognised by the Secretary of State.
2.4 The term ‘Practitioner’ means a registered health care professional who is entitled in accordance with the employer’s procedures to take responsibility for an individual exposure;
2.5 The term ‘Operator’ means ‘ any person who is entitled, in accordance with the employer’s procedures, to carry out practical aspects including those to whom practical aspects have been allocated, medical physics experts and, except where they do so under the direct supervision of a person who is adequately trained, persons participating in practical aspects as part of practical training.
2.6 The term ‘referrer’ means a registered health care professional who is entitled in accordance with the employer’s procedures to refer individuals for exposure to a practitioner.
2.7 The term ‘employer’ means any person who, in the course of a trade, business or other undertaking, carries out (other than as an employee), or engages others to carry out, those exposures described in regulation 3 or practical aspects, at a given radiological installation.
3 Regulatory Background
The purpose of this procedure is to ensure that, in its use of ionising radiation during medical and non-medical exposures, the Trust is compliant with IRMER17 regulation 17.
4 Key Duties
Employer Ensuring staff^ acting as practitioners and operators under IRMER are adequately trained regards their scope of practice, satisfying the requirement in Schedule 3 of IRMER17. Co-operating with other employers as necessary.
Line Manager Ensuring training records for^ staff acting as practitioners and operators are available for inspection:
Medical Physics Expert
To advise on the suitably and frequency of training provided to duty holders.
TRW.H&S.SOP.1278.1 Radiation Safety Training Procedure under the Ionising Radiations Medical
Students are supervised at all times during their placement by qualified and appropriately trained staff. They will complete an induction package relevant to the modality.
Agency:
Agency staff should receive the same standard of training relevant to staff undertaking the same or similar role. The responsibility for the training records remains with the agency employer.
Volunteers:
Volunteer staff should receive the same standard of training relevant to staff undertaking the same or similar role. The responsibility for the training records remains with the employer.
Specialist Roles - Medical Physics Experts:
MPEs appointed by the Trust are required to maintain sufficient CPD to maintain their MPE certification as recognised by Secretary of State – currently portfolio review under RPA2000.
Training Intervals
- Theoretical Training: All staff working in duty holder roles should have refresher theoretical training approximately every 3-5 years.
- Equipment competency will vary depending on individual equipment usage and replacement. This will be defined in the relevant IRMER written procedures.
- Documental review training will occur as documents are up dated or reviewed.
Training Review
Training content should be reviewed periodically, 3 yearly is deemed sufficient, or where there are changes in working arrangements.
The Trust induction training, both face to face and eLearning packages should be reviewed by the Radiation Safety Experts Forum (RSEF) and any changes ratified by the Radiation Safety Committee.
Keeping and Maintaining Records
Records of Professional Registration will be maintained by the Trust Learning and Organisational Development Department.
Records of training delivered through Trust mandatory training programmes should be recorded kept and maintained by the Trust Learning and Organisational Development Department. E.g. IRMER for Referrers
Theoretical, equipment, documental and department continued professional development training delivered within service lines should be kept and maintained by the relevant service line. This should be done such that requirements for refresher training can be identified and to aid management and the radiation safety assurance programme in identifying compliance with staff training requirements
6 Document Ratification Process
The design and process of review and revision of this procedural document will
comply with The Development and Management of Formal Documents.
TRW.H&S.SOP.1278.1 Radiation Safety Training Procedure under the Ionising Radiations Medical
The review period for this document is set as default of five years from the date it was
last ratified, or earlier if developments within or external to the Trust indicate the need
for a significant revision to the procedures described.
This document will be reviewed by the Radiation Safety Committee and ratified by
the Executive Director for Health and Safety.
Non-significant amendments to this document may be made, under delegated
authority from the C&RP Manager, by the nominated author. These must be ratified
by the Executive Director for Health and Safety and should be reported,
retrospectively, to the Radiation Safety Committee.
Significant reviews and revisions to this document will include a consultation with
named groups, or grades across the Trust. For non-significant amendments,
informal consultation will be restricted to named groups, or grades who are directly
affected by the proposed changes.
7 Dissemination and Implementation
Following approval and ratification, this procedural document will be published in the
Trust’s formal documents library and all staff will be notified through the Trust’s
normal notification process, currently the ‘Vital Signs’ electronic newsletter.
Document control arrangements will be in accordance with The Development and
Management of Formal Documents.
The document author(s) will be responsible for agreeing the training requirements
associated with the newly ratified document with the C&RP Manager and for working
with the Trust’s training function, if required, to arrange for the required training to be
delivered.
8 Monitoring and Assurance
Training requirements are reviewed and advised upon by the Trust MPEs as required
by the Radiation Safety Committee. Training records are monitored by the Trust’s
learning and organisation development team and service line area specific training is
audited through the radiation protection assurance programme.
9 Reference Material
Ionising Radiation (Medical Exposures) Regulations 2017
Guidance to the Ionising Radiation (Medical Exposure) Regulations 2017 – DOH June
Trust Standard Operating Procedure No. 427 Procedure for Medical Exposures
