The Ionising Radiation (Medical Exposure) Regulations (Northern Ireland) 2018

Employer’s duties: establishment of general procedures, protocols and quality assurance programmes

6.—(1) The employer must ensure that written procedures are in place in respect of—

(a) those matters described in Schedule 2; and

(b) any other matter in relation to which these Regulations mandate the establishment of procedures.

(2) The employer must take steps to ensure that any written procedures are complied with by the referrer, practitioner and operator.

(3) The employer must take steps to ensure that every practitioner or operator engaged by the employer to carry out exposures or any practical aspect of such exposures—

(a) complies with the provisions of regulation 17(1); and

(b) undertakes continuing education and training after qualification including, in the case of clinical use of new techniques, training related to these techniques and the relevant radiation protection requirements.

(4) The employer must ensure, where appropriate, that written protocols are in place for every type of standard radiological practice coming within these Regulations, including practices involving non-medical imaging.

(5) The employer must—

(a) establish recommendations concerning referral guidelines for medical exposures, including radiation doses, and ensure that these are available to the referrer;

(b) establish quality assurance programmes for written procedures and written protocols;

(c) regularly review and make available to an operator, diagnostic reference levels in respect of an exposure falling within—

(i) regulation 3(a)—

(aa) where the exposure involves interventional radiology procedures, in which case, diagnostic reference levels are to be provided where appropriate; and

(bb) where the exposure does not involve interventional radiology procedures, in which cases regard must be had to European and national diagnostic reference levels where available;

(ii) regulation 3(b), or (e) in which cases regard must be had to European and national diagnostic reference levels where available;

(iii) regulation 3(f) (non-medical imaging) where practicable;

(d) establish dose constraints—

(i) for biomedical and medical research programmes falling within regulation 3(c) where no direct medical benefit for the individual is expected from the exposure; and

(ii) with regard to the protection of carers and comforters falling within regulation 3(d).

(6) A dose constraint must be established by the employer in terms of individual effective or equivalent doses over a defined appropriate time period.

(7) The employer must ensure appropriate reviews are undertaken whenever diagnostic reference levels are consistently exceeded and ensure that corrective action is taken where appropriate.

(8) The employer must take measures to raise awareness of the effects of ionising radiation amongst individuals capable of childbearing or breastfeeding.