**12. Safety protocols**

**11. Radiation exposure as low as reasonably achievable (ALARA)**

68 Vignettes in Patient Safety - Volume 4

excellence can we hope to achieve superior safety for our patients and ourselves.

Advocates for radiation safety recommend exposing patients, especially children, to as little radiation as possible. This is embodied within the concept of "as low as reasonably achievable" (ALARA) in the context of radiation exposure [84]. As such, ALARA addresses the role for healthcare providers, particularly those caring for children, in reducing exposure to radiation while maintaining the reliability of the diagnostic radiology modality [91]. Multiple methods can be used to achieve ALARA including: adjusting the amount of radiation in the diagnostic study based on patient weight, considering alternative modalities such as sonography or magnetic resonance imaging, enhancing shielding with thyroid or breast shields, focusing on the suspicious area with focused or limited view diagnostic imaging, and discouraging repeat CT scan studies [91]. In one example, although noninvasive multi-slice cardiac-computed tomography angiography (CCTA) can accurately screen for coronary ischemia, its widespread utilization has generated concern because of potential diagnostic radiation exposure. Utilization of a radiation dose reduction program in concert with limiting the image acquisition window for CCTA has demonstrated marked reduction, more than 50%, in estimated radiation doses in a statewide

Literature suggesting that accrual of cumulative radiation exposures from diagnostic radiological studies, such as CT scans or fluoroscopy, over the course of patients' lifetimes puts them at risk for the potential carcinogenic risks of radiation [83, 84]. One example here comes from the area of endovascular interventional procedures. Since the introduction of endovascular therapy in the late 1980s, there has been incredible growth in this group of procedural modalities. In fact, endovascular procedures have increased approximately 400% over the past decade [85]. The applicability and medical advancements of this form of therapy have revolutionized treatment of our patients. However, there has been an associated cost, including substantial risk of ionizing radiation exposure [86]. Some of the pioneers of endovascular therapy have succumbed to the deleterious consequence of ionizing radiation [87]. Radiation safety practices have made tremendous advances since the discovery of Roentgen's X-rays over 120 years ago. Early practitioners were focused on patient outcomes and providing minimally invasive methods to treat complex disease processes. These sacrifices of early practitioners led to our awareness and knowledge that now allows us to perform truly remarkable treatments to benefit our patients. A number of very practical steps can be taken to reduce radiation exposure to patients, operators, and staff [88, 89]. Awareness itself can be an effective first step in reducing exposure. Once awareness of the problem exists, we can then work to educate and enact training and methodology to achieve maximal safety to our patients and ourselves. However, despite the available data, there remains a significant safety deficit. In 2014, a survey of US vascular surgery trainees found 45% had no formal radiation safety training, 74% were unaware of the radiation safety policy for pregnant females, 48% did not know their radiation safety officer's contact information, and 43% were unaware of the acceptable yearly levels of radiation exposure [90]. However, an important observation was that the trainees who felt their attendings were applying ALARA techniques were much more likely to do so themselves. Therefore, it is incumbent on those of us providing training to the next generation of caregivers to set an example of excellence and expect the same from our trainees. Only by expecting

Careful adherence to existing PS protocols, including active surveillance for any signs and/or symptoms of HMRE, is among the most important considerations for facilities/departments providing diagnostic and/or therapeutic radiation services [28]. In addition to direct radiation, the formation of X-ray image is inherently associated with some degree of "scattered radiation" that is the principal source of exposure to the patient and medical staff [28]. This "scatter" increases with both intensity of the X-ray beam and the size of the exposed field [28]. Any hospital employing medical radiation needs to have an infrastructure to support protocols for every step of the way throughout the application of said radiation including patient and healthcare worker safety, proper identification and dosing, and waste management of materials in order to prevent contamination.
