Guideline Quick View: Radiation Safety

Publication Date: April 30, 2021
Last Updated: March 14, 2022

Gduideline Essentials


  • Establish a radiation safety program when the potential for occupational radiation exposure exists.
  • Appoint a radiation safety officer (RSO) and a radiation safety committee to lead and direct the radiation safety program.
  • Monitor perioperative team members’ exposure to radiation according to local, state, and federal regulations.
  • Perform an evaluation of the radiation exposure risk or concentrations of radioactive material present to determine the need for dosimetry when there is a change in equipment (eg, purchase of a CT scanner).
  • Provide radiation shielding devices, as indicated by the radiation exposure risk, for all perioperative team members.
  • Retain records (eg, dosimetry reports, radiology films, image records, scans, digital files) according to local, state, and federal regulatory requirements.
  • Provide education upon hire and annually that includes:
    • radiation exposure risks
    • biological effects of radiation exposure
    • principles of radiation protection (eg, time, distance, shielding)
    • principles of dosimetry (eg, one versus two monitors, placement)
    • safe equipment operation
    • regulatory requirements
  • Verify competency of perioperative team members who have the potential for occupational radiation exposure.
  • Allow only qualified personnel to operate a radiologic device.

It is a regulatory requirement for a health care organization to have a radiation safety program when potential for occupational radiation exposure exists.



  • Include in the radiation safety program:
    • a list of the approved equipment operators
    • documentation and record retention requirements
    • measures for protecting patients and perioperative team members from unnecessary exposure to ionizing radiation
    • procedures for handling and disposing of body fluids and tissue that may be radioactive
    • requirements for use, storage, and maintenance of radiation monitoring devices
    • a process and requirements for testing equipment for radiation hazards
    • methods for identifying patients who are pregnant
    • methods for evaluating and selecting new equipment
    • requirements for personnel education and competency assessment
    • a quality assurance and improvement program that includes monitoring of compliance with safety precautions
    • processes for radiographic testing of protective devices
    • requirements for patient education
    • provisions for acceptance testing for protective garments
    • annual exposure limits, which should not exceed those set by the US Nuclear Regulatory Commission (NRC).
  • Review the radiation safety program annually.
  • Maintain records of changes to the radiation safety program, program audits, and individual monitoring results for five years.

A radiation safety program manages the safety of patients and perioperative team members by providing guidance on methods to minimize exposure to ionizing radiation to a level that is as low as reasonably achievable (ALARA).



  • Consult with the RSO or the radiology professional in the room on the use and placement of protective shielding or garments between the patient and the radiation source.
  • Place the shielding:
    • over the patient’s thyroid, ovaries or testes, and breasts when these body parts are near the source of radiation
    • between the patient and the source of radiation
    • between the source and the patient for conventional radiography
    • beyond the edges of the path of the beam that originates from the x-ray tube
  • Perform a radiation safety time out before beginning the procedure.
  • During fluoroscopic procedures, keep the patient as close as possible to the intensifier side of the fluoroscopic unit and away from the tube side of the unit.
  • Move body parts that are not required for the study out of the path of the radiation beam.
  • Provide the patient with education that includes:
    • skin care if signs and symptoms of radiation dermatitis appear
    • signs and symptoms of overexposure to radiation
    • the potential time frame for appearance of signs and symptoms
    • the importance of follow-up with the physician who performed the procedure if questions arise
  • Create a safety policy and procedure for the patient who is premenopausal that includes a:
    • list of procedures that require pregnancy testing
    • method for determining pregnancy
    • process for physician notification if the patient is pregnant
    • method of protective shielding if the patient is pregnant
  • Document the following in the patient’s health record:
    • diagnostic and therapeutic radiation dose
    • type and location of patient radiation protection
    • preprocedural and postprocedural patient skin assessment
    • patient education

Consulting with the RSO or radiology professional can be an effective means of weighing benefits and harms that are specific to the patient and situation. The benefits of using patient shielding include protection of the patient’s radiation-sensitive organs. The harms include an increase in radiation exposure to the patient because the source automatically increases radiation levels.



  • Maintain the greatest distance possible (at least 6 ft) from the radiation source, and limit time spent close to the radiation source.
  • When operating the radiation equipment, alert perioperative team members in the treatment room before activating the equipment.
  • Stand on the image intensifier side of the fluoroscopy unit when possible.
  • Use slings, traction devices, and sandbags to maintain the patient’s position during radiation exposure and use cassette holders to secure films.
  • Wear radiation protective garments during procedures when a source of radiation is activated.
  • Cover the body with the garment from the area below the chin to the knee.
  • Use wraparound garments during clinical activities that may require turning one’s back to the radiation beam.
  • Wear leaded eye protection when unable to distance from the source during activation.
  • Use equipment-mounted and mobile shields in addition to personal shields when perioperative team members are unable to distance from the beam.
  • If used, place radiation shielding drapes between the patient and the operator, outside of the area being imaged, and not between the patient and the source.
  • Visually inspect protective shielding devices for defects (eg, punctures, tears, cuts, creasing) at the time of purchase and before each use.
  • Have personal radiation protective devices tested for shielding effectiveness:
    • at the time of purchase
    • at least annually for defects related to wear
    • whenever damage is suspected
  • Remove devices from use that fail testing or have defects.
  • Maintain records of protective device testing in a central accessible location.
  • Clean and disinfect shared personal protective devices between uses and spot clean them if soiled.
  • Clean protective garments daily if worn by only one individual.

Protective garments that cover the body from the area below the chin to the knee provide shielding from the greatest amount of scatter radiation, including that which is present under the table. Equipment-mounted and mobile shields can provide an added measure of protection from radiation exposure for personnel.



  • Restrict the occupational radiation dose to the levels describe in local, state, and federal regulations for pregnant perioperative team members.
  • Notify the RSO if you know or suspect you are pregnant, or follow other facility channels as defined in policies and procedures.
  • If you are pregnant, follow standard radiation protection techniques and wear a maternity or double- thickness garment, a garment with ancillary shielding, or a wraparound garment that is large enough to cover the entire abdomen.
  • Report monthly dosimeter readings to pregnant perioperative team members.

Effective communication regarding pregnancy status initiates the organization’s practices to monitor for and protect workers who are pregnant from occupational radiation exposure. Timely radiation exposure monitoring of the fetus is important because it allows the mother to know if the dose received is nearing limits and, if so, helps to determine actions to take.



  • Wear radiation monitors if you will be exposed to radiation.
  • Wear dosimeters in a consistent location on the body as determined by the RSO.
  • Wear a dosimeter:
    • on the side of the body that is closest to the radiation source when at the sterile field
    • on the center of the collar when not at the sterile field
    • as recommended by the RSO
  • Wear one dosimeter outside the lead apron and one inside the lead apron or as directed by the RSO or by state regulatory bodies.
  • If you are pregnant, wear a radiation monitor at the waist under shielding in addition to the dosimeter on the collar during times of exposure to radiation.
  • Wear a finger dosimeter when working with the hands in close proximity to the primary x-ray beam, as advised by the RSO.
  • Label dosimeters to indicate the location where they should be worn (eg, inside the apron or vest, outside the apron or vest, at the chest, at the waist).
  • Store radiation monitoring devices or dosimeters at the facility in a designated location at the end of every workday and do not remove them from the facility.
  • Report dosimetry readings to monitored individuals at least annually and more often if the individual is pregnant.
  • Keep dosimetry reports for the life of the individual or as determined by regulatory requirements.

Regulatory agencies provide details for implementation of personnel radiation monitoring. A device that is taken out of the facility may collect ionizing radiation from other sources (eg, sun, soil, airport scanners). Designating a location facilitates collection of the badges for testing and analysis of the device.



  • The health care organization must create policies for use of radionuclides or radiopharmaceuticals and file reports as required by the NRC.
  • Develop processes for:
    • labeling radioactive materials, waste, and hazardous areas
    • storing radioactive materials and waste
    • safe transport of radioactive materials between locations in the hospital
    • measures to maintain security of and access to radioactive materials
    • sterilizing radiation seeds when seed sterilization is required
  • Use radioactive materials under direct supervision of the RSO or an authorized user.
  • Minimize handling of sealed radioactive sources (eg, capsules, seeds, needles, syringes) and irradiated tissues.
  • Wear a covering (eg, lab coat or disposable gown) over the scrub uniform and wear gloves as dictated by the procedure (eg, sterile, unsterile).
  • Limit the number of people in the OR to only those who are essential.
  • Post a sign at all entrances stating, “Radiation in Use.”
  • Verify the activity of sealed sources (eg, seeds) before implantation and after verification, and record:
    • the radioisotope
    • patient’s name or identification number
    • measured level of radioactivity
    • the name of the person who measured the activity
  • Account for all radioactive seeds.
  • Use a standardized marking system (eg, a label on the chart, a wristband on the patient, a sign on the gurney or bed) to indicate that the patient is being treated with a radionuclide or radiopharmaceutical.
  • Notify personnel receiving the patient who has had therapeutic radionuclides inserted that the patient is radioactive and of the radiation source and location.
  • After transport of the patient and before cleaning the OR, consult with the RSO to determine whether a radiation survey should be performed.
  • Consult the RSO about precautions necessary if instruments or linen are found to be radioactive during the survey.
  • Have emergency response equipment specific to the types of radioactive seeds used available near each surgical suite when radioactive materials are handled.
  • Notify the RSO to determine actions to take in the event of a spill.
  • Dispose of radioactive waste according to local, state, and federal regulations.
  • Provide education to perioperative team members regarding handling of therapeutic radiation sources upon hire and annually as applicable to their roles and responsibilities.
  • Provide patients and caregivers with instructions regarding precautions to follow when a patient who has received therapeutic radionuclides is discharged.
  • Document in the patient’s medical record:
    • date and time of therapy
    • radionuclide activity level
    • any special precautions performed as indicated by the RSO
    • patient education.

Therapeutic radiation sources must be handled in accordance with local, state, and federal regulations. The use of radioactive materials in a medical setting is regulated by the NRC or by the state regulatory bodies in an Agreement State, which may have differing regulations.


Recommendation Grading




Guideline Quick View: Radiation Safety

Authoring Organization

Publication Month/Year

April 30, 2021

Last Updated Month/Year

March 16, 2023

Document Type


Country of Publication


Intended Users

Nurse, medical techologist technician surgical technologist, nurse practitioner, physician, physician assistant

Source Citation

Guideline Quick View: Radiation Safety. [No authors listed]AORN J. 2021 May;113(5):531-535. doi: 10.1002/aorn.13402. PMID: 33929731