icat Precise Policy and Procedure Manual

Transcription

1 ORAL SURGERY GROUP P.A. PRACTICE LIMITED TO ORAL AND MAXILLOFACIAL SURGERY DENTAL IMPLANTS, WISDOM TEETH, ORAL PATHOLOGY, AND ORAL MEDICINE Dr. David M. Rauch Dr. Philip S. Engel Dr. Richard K. Stern Dr. Constantine Simos Dr. Michael E. Stern FELLOWS OF THE AMERICAN ASSOCIATION OF ORAL & MAXILLOFACIAL SURGEONS DIPLOMATES OF THE AMERICAN BOARD OF ORAL & MAXILLOFACIAL SURGEONS icat Precise Policy and Procedure Manual Serial Number NU011247

2 Staff Training and Certification Table of Contents 1. Individuals Responsible for QA and QC Program 2. Staff NJ X-Ray License Documentation 3. CBCT Exemption Forms 4. NJ DEP Registration Form icat Precise Policy and Procedure Manual Daily and Weekly QC Tests 1. Tests Performed and Required and Frequencies 2. Description and Acceptable Limits for Each Test Performed 3. Sample Form for Each Test Performed 4. Annual Medical Physicist QC Survey Radiation Policies and Procedures 1. Rules for Radiation Safety 2. Initial Radiation Safety Survey 3. Annual QA Program Review Policy Service and/or Repair Protocol: Plan for Corrective Action Reference Materials Record Keeping 1. QC Tests (for the most recent year) 2. Initial Medical Physicist QC Survey + Two Most Recent Survey s 3. Corrective Action for Two Most Recent Years 4. NJ DEP Inspection Results Most Recent Letter of Compliance

3 Staff Training and Certification

4 Individuals Responsible for QA and QC Program The following staff members are responsible for the QA and QC Program as it pertains to the icat Precise Unit: Angel Willis Primary Shannon Hanson Secondary Jena Bussey Secondary Staff X-Ray License and Training Documentation The following table reflects the all current employees certified to take x-rays in the state of New Jersey. Additionally, staff members trained to take cone beam CT scans is noted. Last Name First Name NJ Lic # License Type X-Ray License Expiration Date CBCT Trained? CBCT Training Completion Date CBCT Training Certificate or Exemption Form? Brown Christina (dental) 12/31/16 No NA NA Bussey Jena (dental) 12/31/16 Yes 01/28/15 Exempt Form Demers Judith (dental) 12/31/16 Yes 11/29/11 Both Devaney Jeannine (dental) 12/31/16 Yes 11/29/11 Both Grosso Jennifer (dental) 12/31/16 Yes 12/18/14 Exempt Form Hanson Shannon (dental) 12/31/16 Yes 01/28/15 Exempt Form Osei Marisa (dental) 12/31/16 No NA NA Reinitz Laura (dental) 12/31/16 No NA NA Reinitz MaryEllen (dental) 12/31/16 Yes 11/29/11 Both Rodgers Barbara (dental) 12/31/16 No NA NA Strok Ada (dental) 12/31/16 No NA NA Willis Angel (dental) 12/31/16 Yes 11/29/11 Both Updated Each new assistant must be trained by a doctor on how to properly use the CBCT scanner. Upon completion, the Licensed Dental Radiologic Technologist CBCT Exemption Form must be completed and signed by the appropriate people. A copy will be put in the employee s permanent file and a copy will also be put into this manual.

5 CBCT Exemption Forms icat Precise Policy and Procedure Manual

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12 New Jersey DEP Registration Form Updated

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14 Quality Control (QC) and Quality Assurance (QA): Daily and Weekly Tests

15 Tests Performed and Required Frequencies icat Precise Policy and Procedure Manual In order to maintain the quality assurance protocol, there are a number of tests that need to be performed on the CBCT scanner. The tests and associated frequency in which they are to be performed are listed in the table below. When performing each test, the corresponding worksheet in the QA Log Book (green) is to be completed. The staff member completing each test is to date and initial the top of the worksheet. The following tests need to be executed by a qualified and licensed staff member: Test QA Water Phantom Test Field Uniformity Calibration Collimation Frequency Required by NJ DEP Daily Required by NJ DEP Daily Required by manufacturer Weekly Required by manufacturer Weekly The following tests need to be executed annually by a qualified Medical Physicist. Test Low Contrast Resolution High Contrast Resolution Noise Scan Localization Light Accuracy Medical Physicists QC Survey Quality Assurance Program Review The following tests do not need to be performed, as they do not pertain to Oral Surgery Group. These tests are for offices that use film. Test Film Processing QC Test Laser Film Printer QC

16 Description and Acceptable Limits of Each Test Performed

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23 Sample Test Form icat Precise Policy and Procedure Manual

24 Annual Medical Physicists QC Survey Performed icat Precise Policy and Procedure Manual

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26 Radiation Policies and Procedures

27 Rules for Radiation Safety 1. Only individuals required for the medical procedure, for training, or for equipment maintenance shall be in the radiographic room during an exposure. 2. Only staff members and doctors with a New Jersey Radiological License in good standing will be permitted to operate CBCT scanner and position a patient for radiographic exposure. 3. Individuals present during the radiographic exposure shall wear a protective apron of at least 0.25mm lead equivalent during every exposure. 4. When a patient must be provided with auxiliary support during a radiation exposure and mechanical holding devices are insufficient, the following procedures shall be followed: a. The person holding the patient shall be protected with a lead apron of at least 0.25mm lead equivalent. b. No licensed practitioner shall order or otherwise cause a New Jersey licensed technologist to hold a patient during radiation exposure, except in a life threatening situation. c. No person shall be employed, routinely assigned, or required to hold a patient during a radiographic exposure. d. If a person must be held during the x-ray exposure, non-radiation workers such as aides, orderlies, nurses, or members of the patient s family may be asked to perform this duty. 5. Gonadal shielding of not less than 0.5mm lead equivalent shall be used on a patient during radiographic procedures. 6. On units that do not have positive beam limitation, the operator shall collimate x-ray beam to ensure that the field does not extend beyond the image receptor. 7. The radiographic field shall be restricted to the area of clinical interest as far as practical.

28 8. A mirror attached to the adjacent doorway is the object employed to observe the patient during the x-ray. 9. Observation of the patient shall be made from the shielded area. 10. During radiographic exposure, the operator shall stand behind the protective barrier. 11. No person shall permit or arrange for the intentional irradiation of a human being except for the purpose of medical diagnosis or treatment. 12. Before taking any x-rays, operators must ask female patients of child bearing age about the possibility of pregnancy. If the patient is unsure, the procedure should be delayed until the pregnancy status is confirmed. 13. Signs should be placed near the CBCT scanner reminding the patient to inform the doctor/technologist if they are pregnant. 14. Pregnant radiation workers shall be provided with a personal radiation monitoring device to assure the allowable limits to the fetus is not exceeded. Oral Surgery Group policy regarding pregnant staff members taking x-rays is written in the Oral Surgery Group Employee Handbook. 15. All staff members who operate the CBCT scanner are to sign below stating they have read the safety manual: Operator Printed Name Operator Signature Date

29 Initial Radiation Safety Survey Performed icat Precise Policy and Procedure Manual

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33 Annual QA Program Review Policy The QA and QC Policy and Protocol will be reviewed on an annual basis, in conjunction with the annual Medical Physicist Survey (every October). Review of this manual and its contents will be evaluated and updated, as necessary, at that time also.

34 Service and/or Repair Protocol: Plan for Corrective Action

35 When performing the Phantom Water Test, you must confirm that the mean is within the normal limits of (+) or (-) 90. If the mean is not within this range, DO NOT USE THE UNIT! Call ISI and speak with Technical Support. icat Precise - Imaging Sciences International (ISI) (800) Option 5 = Technical Support If you have questions regarding the testing process, you can contact: Steve Glennon, Medical Physicist RJ Tokarz Medical Imaging Radiation Safety Corporation (732) steve@jerseyphusics.com

36 Reference Materials

37 Information for this manual was obtained from the following sources: 1. New Jersey Department of Environmental Protection, Bureau of Radiological Health, PO Box 415 Trenton, NJ icat Precise Operators Manual. Version Revision B May 1.

38 Record Keeping icat Precise Policy and Procedure Manual

39 QC Tests for the Most Recent Year All daily QC tests for the last two years are filed at the end of this section. Test images from the daily calibrations have been saved in the icat Vision. Initial Medical Physicist QC Survey Performed

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43 Most Recent Medical Physicist Survey (2 most recent years surveys) Survey #1 Performed icat Precise Policy and Procedure Manual

44 Survey #2 Performed icat Precise Policy and Procedure Manual

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46 Corrective Action for Two Most Recent Years None.

47 NJ DEP Inspection Results icat Precise Policy and Procedure Manual

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