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In case of a service using radiation orradioactive substances are thereeffective arrangements in place tocontain the incident e.g. such asradioactive spillage while carrying outa PET-CT scan or another form ofnuclear medicine imaging?920200715 9001265 NHS Acute(*) and Independent Acute Hospitals Diagnostic Imaging (*additional) service framework NP v4

Key line of enquiry: S2S2. How are risks to people assessed, and their safety monitored and managed so they are supported to stay safe?Report sub-heading: Assessing and responding to patient riskPromptsProfessional standardSector specific guidance Sepsis: recognition, diagnosis andearly management (NICE Guideline51) Is there a policy for sepsis managementand are staff aware of it? National Safety Standards forInvasive Procedures (NatSSIPs)Version number: 1 published: 7September 2015 Brief guide: NatSSIPs and LocSSIPs Standards for the communication ofradiological reports and fail-safe alert S2.5 Are comprehensive risk assessmentscarried out for people who use services andrisk management plans developed in linewith national guidance? Are risks managedpositively?S2.6 How do staff identify and respondappropriately to changing risks to peoplewho use services, including deterioratinghealth and wellbeing, medical emergenciesor behaviour that challenges? Are staff ableto seek support from senior staff in thesesituations? HSIB report on communicatingunexpected significant findings Guidance on implementing safetychecklists for radiological procedures If children are treated there should bespecific paediatric protocols in placefor all imaging modalities. Are there clear pathways and processesfor the management of people usingservices within radiology departmentswho are clinically unwell and requirehospital admission? Are there processes to ensure the rightperson gets the right radiological scan atthe right time? Does the service follow the RCRstandards for the communication ofradiological reports and fail-safe alertnotification? Does the service check three points of IDand/or use the society of radiographers“pause and check”? Are there clear pathways andprocesses for staff to assessoutpatients using services in radiologydepartments who are clinically unwelland need hospital admission?1020200715 9001265 NHS Acute(*) and Independent Acute Hospitals Diagnostic Imaging (*additional) service framework NP v4

Notes for guidance on the clinicaladministration ofRadiopharmaceuticals and use ofsealed Radioactive Sources:Guidance on the clinicaladministration ofRadiopharmaceuticals and use ofsealed radioactive sources How does the imaging serviceensure that the radiation protectionadvisor and the medical physicsexpert are easily accessible forproviding radiation advice? Has the service appointed radiationprotection supervisors, In departmentswhich uses ionising radiation? The employer’s written procedures forexposures must include procedures—How does the service ensure that the‘requesting’ of an X-ray, nuclearmedicine or other radiation diagnostictest, e.g. by GP’s or others is only madeby staff / persons in accordance withIR(ME)R? Does the service adoptreferral criteria? (d) to ensure that quality assuranceprogrammes in respect of writtenprocedures, written protocols, andequipment are followed;Do staff do a debrief or give othersupport after aggressive or violentincidents? How does the imaging service ensurethat women (including patients andstaff) who are or may be pregnantalways inform a member of staffbefore they are exposed to anyradiation in accordance with IR(ME)Rand for staff in accordance with IRR? Is there a pregnancy procedure inplace? What are the local policies for the risk Protecting pregnant patients duringdiagnostic medical-exposures The impact of IR(ME)R 2017 onpregnancy checking procedures IRMER Regulations 2017, Schedule 2should be in place:(k) to ensure that the probability andmagnitude of accidental or unintendedexposure to individuals fromradiological practices are reduced sofar as reasonably practicable guidance on gadolinium basedcontrast agent administration in adultpatients1120200715 9001265 NHS Acute(*) and Independent Acute Hospitals Diagnostic Imaging (*additional) service framework NP v4

RCR endorsement of the 2016RANZCR Iodinated ContrastGuidelines which can be viewed ontrast-guidelines rsions/safety in magnetic resonance imaging 3.pdf assessment and prevention ofcontrast-induced nephropathy? Arethey in keeping with NICE Acutekidney injury guidelines and the RoyalCollege of Radiologists standards forintravascular contrast agentadministration? The potential risks of intravascularadministration of contrast must beweighed against the potential benefits.Systems need to be in place including trained individuals that are able torecognise and treat severe contrastreactions, including anaphylaxis. Thiscould be a registered nurseor radiographer or other appropriatelytrained healthcare professional. Do they use SCoR Pause and Check,or a similar version adapted by theorganisation? Guide to IRMERCancer NICE guidance CG151: Neutropenicsepsis: prevention and managementin people with cancer What are the local policies todocument, investigate, and make areferral to a specialist allergy serviceand the process for advising thepatient in cases where significantsuspected contrast reactions aresuspected?Are there clear processes to escalateunexpected or significant findings bothat the examination and uponreporting? How are these flagsescalated where reported byteleradiology services?Are there procedures for the collapseof a patient in MRI, and are thesepractised? Have managers ensured that there is aplan in place to develop local SafetyStandards for Invasive Procedures usingthe national Safety Standards forInvasive Procedures. Have theyassessed the need for these against allinvasive procedures carried out? i.e. for1220200715 9001265 NHS Acute(*) and Independent Acute Hospitals Diagnostic Imaging (*additional) service framework NP v4

US guided drainages or CT guidedbiopsies Do they have processes in place to directpatients as to what to do if they have acomplication post procedure? Are there local rules (IRR) andemployers procedures (IR(ME)R)which protect staff and patients fromionising radiation? For services that treat children, whatadditional wider arrangements are therein place to manage a deteriorating child?For example if a child needs a crashteam. How are staffing requirements assessedor calculated? Do they use agency? What are the localinduction policies? Does the provider carry out riskassessments to minimise risksassociated with lone working? For services that treat children, isthere access to a member of staff skilledin Advanced or European Paediatric LifeSupport?Report sub-heading: Staffing S2.1 How are staffing levels and skill mixplanned and reviewed so that people receivesafe care and treatment at all times and staffdo not work excessive hours?Cancer Health Education England – CancerWorkforce PlanS2.2 How do actual staffing levels and skillmix compare with the planned levels? Iscover provided for staff absence?S2.3 Do arrangements for using bank,agency and locum staff keep people safe atall times?1320200715 9001265 NHS Acute(*) and Independent Acute Hospitals Diagnostic Imaging (*additional) service framework NP v4

S2.4 How do arrangements for handoversand shift changes ensure that people aresafe?Cancer How does the provider ensure adequatediagnostic staffing, identified by HealthEducation England as experiencingshortages in the provision of cancerservices:o Clinical Radiologyo Diagnostic RadiographyS2.7 How is the impact on safety assessedand monitored when carrying out changes tothe service or the staff?Report sub-heading: Medical staffing S2.1 How are staffing levels and skill mixplanned and reviewed so that people receivesafe care and treatment at all times and staffdo not work excessive hours? S2.2 How do actual staffing levels and skillmix compare with the planned levels? Iscover provided for staff absence?S2.3 Do arrangements for using bank,agency and locum staff keep people safe atall times? Where intravascular contrastadministration is carried out, systemsneed to be in place including trainedindividuals that are able to recogniseand treat severe contrast reactions,including anaphylaxis. This could be aregistered nurse or radiographer orother appropriately trained nistrationadult-patients-third-editionS2.4 How do arrangements for handoversand shift changes ensure that people aresafe? Can the radiographers contact aradiologist for advice as the radiologistmay not always be onsite? How are staffing requirementsascertained? Do they use agency? What are the localinduction policies? Does the provider carry out riskassessments to minimise risksassociated with lone working? Does the service use teleradiologyservices for out of hours work and/ornormal reporting? Is there access tothese radiologists? Is there access to an appropriatelytrained clinician when contrast isadministered?S2.7 How is the impact on safety assessedand monitored when carrying out changes tothe service or the staff?1420200715 9001265 NHS Acute(*) and Independent Acute Hospitals Diagnostic Imaging (*additional) service framework NP v4

Key line of enquiry: S3S3. Do staff have all the information they need to deliver safe care and treatment to people?PromptsProfessional standardSector specific guidanceReport sub-heading: Records S3.1 Are people’s individual care records,including clinical data, written and managedin a way that keeps people safe? S3.2 Is all the information needed to deliversafe care and treatment available to relevantstaff in a timely and accessible way? (Thismay include test and imaging results, careand risk assessments, care plans and casenotes.) S3.3 When people move between teams,services and organisations (which mayinclude at referral, discharge, transfer andtransition), is all the information needed fortheir ongoing care shared appropriately, in atimely way and in line with relevantprotocols?S3.4 How well do the systems that manageinformation about people who use servicessupport staff, carers and partner agencies todeliver safe care and treatment? (Thisincludes coordination between differentelectronic and paper-based systems andappropriate access for staff to records.) Records management code ofpractice for health and social care ity-statement-3Information-exchange GMC guidance on keeping records NICE QS121 Statement 3: Peopleprescribed an antimicrobial have theclinical indication, dose and durationof treatment documented in theirclinical record. Standards for the provision ofteleradiology Brief guide on teleradiology Does the service provideelectronic access to diagnosticresults? How does the service ensure imagingrequests are appropriate and includethe relevant information to allow forrequests to be justified in accordancewith IR(ME)R? Does this includeinformation relevant to keep patientssafe? Where appropriate, is patientinformation transported with patientswhen attending a scan or procedure?Are staff aware of relevant clinical andcare requirements i.e. Fallassessments, DNACPR, NBM,pregnancy, renal function if contrast isto be used?As part of the justification process tocarry out exposure to radiation, howdoes the imaging service attempt tomake use of previous images of thesame persons requiring the test, even ifthese have been taken elsewhere?1520200715 9001265 NHS Acute(*) and Independent Acute Hospitals Diagnostic Imaging (*additional) service framework NP v4

When appropriate, do recordscontain details of patients’o mental health needso learning disability needso autism needso dementia needsalongside their physical health needs? Does the service have processes toensure that transport of patients toradiology includes relevant clinicalinformation e.g. infection risks or resusinfo or escort and porteringrequirements? Where used, is there a secure transferof data to and from teleradiologycompanies? Where there are multiple IT systems,how do they ensure information isshared and accessed when required?Independent healthcare: Is there a system in place to ensure thatmedical records generated by staffholding practising privileges areavailable to staff (or other providers)who may be required to provide care ortreatment to the patient?Cancer1620200715 9001265 NHS Acute(*) and Independent Acute Hospitals Diagnostic Imaging (*additional) service framework NP v4

Is there an adequate system to ensurethe diagnostic service’s access to cancerpatient records, whether paper orelectronic? If there are there multiple IT systems i.e.Electronic Patient Records and aseparate cancer information system, howdoes the service ensure timely transferof information between them?1720200715 9001265 NHS Acute(*) and Independent Acute Hospitals Diagnostic Imaging (*additional) service framework NP v4

Key line of enquiry: S4S4. How does the provider ensure the proper and safe use of medicines, where the service is responsible?PromptsProfessional standardSector specific guidance Are contrast media and othermedicines stored correctly? Are Patient Group Directions inplace, or are medicines prescribedby doctors or registered non-medicalprescribers? What processes are there to ensurethat the right radiopharmaceuticaland activity is sourced, prepared andinjected? Do radiologists hold appropriateARSAC licenses for theadministration of each radioactivemedicinal product?Report sub-heading: Medicines S4.1 How are medicines and medicinesrelated stationery managed (that is, ordered,transported, stored and disposed of safelyand securely)? (This includes medical gasesand emergency medicines and equipment.)S4.2 Are medicines appropriately prescribed,administered and/or supplied to people inline with the relevant legislation, currentnational guidance or best availableevidence?S4.3 Do people receive specific advice abouttheir medicines in line with current nationalguidance or evidence?S4.4 How does the service make sure thatpeople receive their medicines as intended,and is this recorded appropriately?S4.5 Are people's medicines reconciled inline with current national guidance ontransfer between locations or changes inlevels of care?S4.6 Are people receiving appropriatetherapeutic drug and physical healthmonitoring with appropriate follow-up inaccordance with current national guidance orevidence? NICE QS121 Statement 4: Peoplein hospital who are prescribed anantimicrobial have a microbiologicalsample taken and their treatmentreviewed when the results areavailable.Start Smart then Focus:Antimicrobial Stewardship ToolkitRCR guidance on sedation,analgesia and anaesthesia in theradiology department otes-for-guidance Products administered withradiopharmaceuticals can be done bya non-healthcare profession: Is there clear delegation for injectingradiopharmaceuticals Is this clearlydocumented?Guidance for the administration ofmedicinal products by non-medicalpersonnel Where medicines are administered inconjunction with a radioactive medicinalproduct, is this undertaken safely asspecified by the Human MedicinesRegulations 2012 as amended?1820200715 9001265 NHS Acute(*) and Independent Acute Hospitals Diagnostic Imaging (*additional) service framework NP v4

S4.7 Are people’s medicines regularlyreviewed including the use of ‘when required’medicines?S4.8 How does the service make sure thatpeople’s behaviour is not controlled byexcessive or inappropriate use of medicines? How is the use of medicines such asfurosemide risk assessed anddocumented so it can be administered bystaff?1920200715 9001265 NHS Acute(*) and Independent Acute Hospitals Diagnostic Imaging (*additional) service framework NP v4

Key line of enquiry: S5& S6S5. What is the track record on safety?S6. Are lessons learned and improvement made when things go wrong?PromptsProfessional standardSector specific guidanceReport sub-heading: Incidents S5.1 What is the safety performance overtime? S5.2 How does safety performance comparewith other similar services? S5.3 How well safety is monitored usinginformation from a range of sources(including performance against safety goalswhere appropriate)? S6.1 Do staff understand theirresponsibilities to raise concerns, to recordsafety incidents, concerns and near misses,and to report them internally and externally,where appropriate? S6.2 What are the arrangements forreviewing and investigating safety andsafeguarding incidents and events whenthings go wrong? Are all relevant staff,services, partner organisations and peoplewho use services involved in reviews andinvestigationsS6.3 How are lessons learned, and themesidentified and is action taken as a result ofinvestigations when things go wrong? A never event is a serious incidentthat is wholly preventable asguidance, or safety recommendationsproviding strong systemic protectivebarriers, are available at a nationallevel, and should have beenimplemented by all providers. Theevent has the potential to causeserious patient harm or death, hasoccurred in the past and is easilyrecognisable and clearly defined.never-events-policy-and-frameworkNever events 2018 Serious Incidents (SIs) should beinvestigated using the SeriousIncident Framework 2015. (NICE QS66 Statement 4): For adultswho receive intravenous (IV) fluidtherapy in hospital, clear incidents offluid mismanagement are reported ascritical incide

2 20200715 9001265 NHS Acute(*) and Independent Acute Hospitals Diagnostic Imaging (*additional) service framework NP v4 IMPORTANT - Prior to inspecting any service which included MRI or ionising radiation, you must be aware of the