Profile of the institution
Each year,
the Hospital attends 2,800,000 consultations,
manages 46,500 discharges and performs 52,000 surgical procedures in its 41 operating theaters.
It has a capacity of 785 beds,
of which 200 are for critical care,
and 800 beds of home medicine.
Its work team is made up of 9237 people: 3400 medical doctors,
3337 members of the health staff and 2,500 people from the administrative sectors.
As for the assistance it provides,
the Italian Hospital has more than 40 medical specialties,
a complete diagnostic and treatment equipment,
and a recognized professional staff.
In addition,
it has its own university that dictates careers in Nursing,
Medicine,
Biochemistry and Pharmacy,
and the Institute of Basic Sciences and Experimental Medicine.
The imaging department staffing is detailed in Table 1.
During 2018,
583,455 patients were attended.
The patient distribution per area is described in Table 2.
Global and Specific actions
1.- A strategic decision of creating a Radioprotection Commitee (RPC) was taken institutionally.
The RPC integrated a multidisciplinary team of auditors (composed by medical experts in the use of ionizing radiation,
radiation physics,
radiation oncology,
nuclear medicine,
interventional radiologists,
etc.-) as well as experts in other safety and quality aspects of health care (clinical engineering,
occupational health ,
etc.) to perform an internal audit program.
A team leader was designated and responsible for organizing the tasks and preparing the final report making sure that no conflict of interest existed between the auditors and the areas to be audited.
2.- The RPC determined the objective of the internal audit program and the methodology for the planning,
preparation and documentation of the internal radioprotection audits.
3.- The scope was defined: all Hospital services that use ionizing radiation,
in particular,
areas of the diagnostic imaging department.
4.- The audit plan was established:
4.a.-An audit plan had been planned and maintained annually (Figure 1) in each area of the diagnostic imaging department.
4.b-This plan established the frequency of completion of the audits in order to cover a
evaluation of all areas and activities of the departments at least one once in the year.
4.c-The frequency of audits could be increased in areas or processes where
significant problems are find or special reasons that imply an additional evaluation.
4.d-The annual audit plan and the dates were communicated to all staff.
5.- To ensure adequate preparation of the audit,
a month before the established date of the audit,
the group of auditors,
analyzed the following aspects to be evaluated (procedures and protocols must be available in the sectors to be audited):
-Previous audits results,
-Patients complaints related to radioprotection,
-Radiation protection elements (existence,
controls performed,
etc.),
-Personal Dosimetry,
-Protocols,
-Studies dosimetry vs.
Local DRLs,
-Need for personal training in radiation protection issues,
-Use of checklist for each area (Figure 2 and 3) based on the procedures applicable to the area to be audited,
which will serve as a guide during the audit
6.-The following subjets had been evaluated:
-Appropriateness use of protocols,
techniques and elements of radiological protection of the patient,
-Dose management plan results,
comparison between studies dosimetry ovs.
Local DRLs
-Personal dosimetry reports (in our country the occupational medicine department must supply this information).
-Leaded aprons quality controls reports (in our country the safety and hygiene department supply this information).
-Quality controls reports
At the end of the audit,
the lead auditor drew up a report containing the findings and
recommendations.
Within each report,
information from specific areas as clinical engineering,
safety and hygiene and occupational medicine was included.