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Beyond the Data: The Human Side of Radiation Dose Monitoring: Part III - File a Flight Plan

Olav Christianson, MS DABR

Now that you have your dream team set up and have created dose protocols for communication with your patients, it's time to build your flight plan.  No airline crew would take off and fly at 30,000 feet without knowing the rules of flight, the route to follow, and the speed and altitude that are optimum for the flight. One of the most critical radiation department objectives is to minimize unnecessary radiation for both patients and staff. For any radiation dose monitoring system to be effective and provide measurable performance metrics, the following three steps need to be part of your flight plan for radiation dose measurement strategy:

  • Flight rules (Standards and regulations)
  • Route to be followed (imaging protocols)
  • Speed and altitude (expected dose ranges)

Standards and Regulations

  • Document CT and fluoroscopy dose data in a retrievable format
  • Establish CT protocols including the expected dose range
  • Set up processes for reviewing and analyzing CT incidents that exceed standards
  • Establish fluoroscopy expected dose ranges and thresholds for patient follow up
  • Set up processes for reviewing and analyzing fluoroscopy incidents that exceed standards

Imaging Protocols

  • Clinical Indication
  • Contrast administration
  • Age (adult vs. pediatric)
  • Patient size and body habitus
  • Expected radiation dose index range

Determining imaging protocols requires considering several factors, including deciding what your key performance indicators (KPI) will be and what external benchmarks will inform your KPIs. External benchmarks to consider are diagnostic reference level (DRL): 75th percentile of the dose to a given population, and the achievable dose (AD): 50th percentile of the dose to a given population.  Some additional considerations include: neither the DRL nor the AD are hard limits, DRL and AD should never be applied to individual patients, understand the capabilities of the imaging equipment, and consider the patient population when setting goals.

Expected Radiation Dose Ranges


  • Avoid alert fatigue
  • Keep it simple
  • Justify your selection
  • Document everything


  • Apply ACR pass/fail as a threshold
  • Use fixed percentages of studies
  • Create an enormous number of rules
  • Treat expected dose ranges as hard limits

Establishing expected radiation dose ranges are critical to getting accurate KPIs. Be sure to include all sources of radiation when setting up your plan. Additional notification or threshold levels that should be considered include:

Fluoroscopy dose notification levels: 

  • Used to raise awareness during a procedure
  • Never stop a procedure only because a notification level was exceeded

Substantial radiation dose level (SRDL):

  • Triggers organization’s patient follow-up process
  • Never stop a procedure only because a SRDL was exceeded

Sentinel dose event

  • This is for skin dose, not the cumulative air kerma reported by the machine
  • The Joint Commission recommends establishing a trigger to identify possible Sentinel Events
  • The Joint Commission does not mandate keeping cumulative radiation dose records but says, “routine monitoring of the parameters identified in this new sentinel event definition would be an appropriate patient safety precaution.”

CT notification levels

  • Used to raise awareness prior to expos
  • Never stop a study only because a notification level was exceeded

CT Alert Levels

  • Used to raise awareness during a study
  • Never stop a study only because a notification level was exceeded
  • Watch out for interventions

Watch Olav Christianson’s complete webinar on Beyond the Data: The Human Side of Monitoring. LANDAUER also provides data on this topic and many others that pertain to radiation monitoring and safety. It is updated regularly so, be sure to visit our site often.