College of Life and Environmental Sciences Health and Safety Standard

Management of Laboratory Procedures Involving Medical or Research X-ray Exposure
Date of Approval June 2014 Expiry Date June 2016
Author and Lead Dr Luis Gracia Marco, Lecturer, Sport and Health Sciences, CLES, University of Exeter (DXA Laboratory Coordinator).
Mr David Childs, Senior Laboratory Manager, Sport and Health Sciences, CLES, University of Exeter.
Aims The College of Life and Environmental Science (CLES) is committed to ensuring the health, safety and welfare of all staff, students and visitors. This Standard defines the responsibilities for the management of medical x-ray exposure to individuals taking part in research studies within CLES.
Scope This standard applies to the Dual Energy X- ray Absorptiometry (DXA) laboratory in Baring Court, St. Lukes Campus.
Definitions Children and Young People Undertaking activities in Laboratories
Relevant Legislation Ionising Radiation (Medical Exposure) Regulations 2000, amended 2006 (IRMER) Ionising Radiation Regulations 1999 (IRR99) HSE Guidance Note PM77: Equipment used in connection with medical exposure
Responsibility for implementation College and Professional Services
Training availability: Please contact Dr. Luis Gracia Marco in the first instance
Standard to meetAccountabilityReference documents and more information
1. Annual DXA Laboratory User Group Meeting
The DXA Laboratory Coordinator will convene an annual meeting of all persons involved in the IRMER management structure of the DXA Laboratory in order discuss and review as necessary the operational procedures of the laboratory.
DXA Laboratory Coordinator
2. Roles and Responsibilities
The Definition of Roles and Responsibilities for IRMER Compliance sets out requirements and duties for the following key post holders:
•    The College Dean
•    The DXA Laboratory Coordinator
•    The Referrer
•    The Practitioner
•    The Medical Physics Expert
•    The Radiation Protection Adviser
•    The University Radiation Protection Officer
•    The Radiation Protection Supervisor
•    The Operator
All staff involved in the management or carrying out of medical or research x-ray exposures within the DXA Laboratory Definition of Roles and Responsibilities for IRMER Compliance (.pdf)

List of named individuals with responsibilities for IRMER compliance (.pdf)
3. Standard Operating Procedures:
•    Initiating a research project involving the use of DXA
•    Establishment of pregnancy status
•    Management and storage of data
•    Measurement procedures and protocols
•    Analysis procedures and protocols
•    Emergency procedures and protocols
•    Staff training and professional development
•    Standard forms and recording sheets
All staff involved in the management or carrying out of medical or research x-ray exposures within the DXA Laboratory Establishment of pregnancy status (.pdf)
4. Local Rules for the DXA laboratory (IRR99) All approved DXA operators Local rules and risk assessment (.pdf)
5. Laboratory management and PM77 compliance Laboratory manager  
Standard Monitoring and Measurement Criteria
Annually the Standard will review key aspects of compliance as below. A compliance and performance report will be submitted to the College H&S Committee annually. Where necessary a corrective action plan will be put into place where performance in the annual policy monitoring indicates improvements are needed
1. DXA Laboratory audit procedures