Why Radiology Safety Matters

Radiology is one of the few areas where a facility can pass equipment inspection, issue the badges, and still fall short in daily practice. Recent QUAD A surveys show the same gaps repeating in radiation safety practices, staff qualifications, and documentation. This article covers what surveyors look for in four areas (qualified personnel, staff safety and PPE, equipment readiness, and dosimetry) and the steps that keep a radiology program ready between surveys. 

Radiology services support diagnosis and treatment, but they also introduce regulated safety risks that require continuous oversight. Recent QUAD A surveys show recurring deficiencies in radiation safety practices, staff qualifications, and documentation. Addressing these issues strengthens patient safety, reduces exposure risk, and supports ongoing accreditation readiness.

Qualified Personnel

Facilities must ensure that only individuals qualified under applicable state law operate, move, reposition, set up, or adjust radiologic equipment such as C‑arms, X‑ray tables, and portable units.

• Review and maintain a current copy of your state laws and regulations related to radiology services applicable to your facility type and have it readily accessible to the surveyor.
• Verify credentials regularly when licensure, certification, or registration is required, verify current credentials and maintain documentation in a location that is readily accessible to surveyors.
• Define permitted activities to clearly identify which activities may be performed by credentialed and non-credentialed individuals, based on applicable state law and the individual's role and scope of practice.
• Provide structured training and competency validation when state law allows non-credentialed individuals to perform limited tasks, provide documented training and competency validation appropriate to the tasks performed for both credentialed and non-credentialed staff.
• Establish supervision and oversight when required by state law or facility policy, ensure appropriate supervision and oversight of individuals performing permitted tasks.
• Maintain role clarity by establishing clear role definitions and documented competencies to prevent individuals from performing activities beyond their legal authorization, training, or demonstrated competency.

Staff Safety & PPE

Consistent use of personal protective equipment (PPE) is essential to maintaining safe radiologic practices and reducing exposure risk. Facilities should reinforce correct use in alignment with written policy and standard precautions, including:

• When PPE is required, incorporating reminders into daily workflows.
• Proper selection, use, and storage, reinforced through onboarding and periodic training.
• Availability and condition, ensure required PPE is readily available, appropriately located, and maintained in good condition. PPE should be inspected before use and removed from service if damaged or otherwise ineffective.
• How PPE supports radiation protection principles, educate staff on the role of PPE in reducing radiation exposure and reinforce the principles of minimizing exposure through thought time, distance, and shielding.

Equipment Readiness & Safety Controls

Facilities must ensure radiologic equipment is safe, functional, and compliant with state and local requirements.

• Verify shielding and safety features during setup to ensure they match state/local requirements and manufacturer IFUs. Incorporate these checks into routine room‑readiness procedures.
• Post radiation signage where it is immediately visible to anyone approaching the area. Signs should be checked during daily opening procedures to confirm they haven’t been moved or obstructed.
• Schedule and track annual inspections for all X‑ray equipment and lead aprons. Maintain a simple log or binder that staff and surveyors can review quickly, and ensure any identified hazards are corrected without delay.
• Document equipment cleaning and operability checks before each patient use. A brief checklist or electronic log helps staff demonstrate consistency.
• Reinforce malfunction reporting procedures so staff can clearly describe who to notify and what immediate safety steps to take.

Dosimetry

When required, facility policies must address:

• Badge assignment, maintenance, monitoring, and storage
• Staff use of dosimetry badges
• Exposure record retention for at least three years when X‑ray is used

Because state requirements vary, facilities should always follow the stricter requirement.

Why Ongoing Vigilance Matters

Unsafe radiation practices increase the risk of harm to patients, staff, and visitors. For QUAD A facilities, radiation safety is a core component of high‑quality care. Daily attention to safe practices ensures compliance, protects individuals, and strengthens survey readiness.

Additional Regulatory Resources

Facilities participating in the ASC and RHC programs are encouraged to refer to the Centers for Medicare & Medicaid Services (CMS) State Operations Manual (SOM) for detailed clarification on regulatory requirements relevant to their accreditation. The SOM provides interpretive guidelines and survey procedures to help ensure compliance with federal standards.

• Appendix L – ASC: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_l_ambulatory.pdf

• Appendix G – RHC: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_g_rhc.pdf
  

For additional information and guidance on radiation safety, the resources below may support your practice to maintain compliance and enhance safety protocols:
Radiation Protection | Nuclear Regulatory Commission
Ionizing Radiation - Standards | Occupational Safety and Health Administration
Training and Reference Materials Library | Occupational Safety and Health Administration

Questions 

For assistance with PSDR or adverse event reporting, please contact the QUAD A Patient Safety Data Reporting HelpDesk via email at helpdesk@quada.org.

Since 1980, QUAD A (a non-profit, physician-founded and led global accreditation organization) has worked with thousands of healthcare facilities to standardize and improve the quality of healthcare they provide – believing that patient safety should always come first.