Clinical audit in radiological protection

Abstract

Introduction: Law 108/2018, of December 3, establishes the legal framework for radiological protection in Portugal, and one of the new features introduced, in relation to the previous legal framework, is the legal obligation to carry out clinical audits, analysing and reviewing radiological procedures, seeking to improving the quality of care provided to patients, in accordance with approved standards and recognized good medical radiological procedures.

Objective: Develop and apply a clinical audit model, within the scope of radiological protection.

Methods: A risk map was created, based on current legislation, recognized good practices and scientific reference articles. The study was carried out in February 2024, at ULS Médio Tejo. Data collection was done through semi-structured interviews and existing documentation in the hospital database. 

Results: Results: The 60 indicators were classified as high (36%), moderate (52%), and low (12%) risk. 37 were compliant, 10 showed opportunities for improvement, and 13 showed nonconformities, of which 46% were classified as high risk and 54% as moderate. The excellent collaboration and quality culture within the Service, as well as the constant review of processes for improvement, were highlighted. However, outdated documentation was present, and it was appropriate to create forms for greater process control.

Conclusions: A clinical audit model was developed and implemented. The main role of the Radiation Protection Officer was also demonstrated, not only to comply with legal requirements and avoid potential large fines, but also to the desired process of continuous quality improvement.