Radiological facilities must be fitted out in accordance with the provisions of ASN resolution 2017-DC-0591 of 13 June 2017. This resolution applies to all medical radiology facilities, in– cluding computed tomography and dental radiology. It does not however apply to X-ray generators that are used exclusively for bedside radiography and excluding any use in fluoroscopy mode. A technical report demonstrating conformity of the facility with the requirements of the ASN resolution must be drawn up by the person or entity responsible for the nuclear activity. Portable X-ray generating devices ASN and the Dental Radiation Protection Commission (CRD) published an information notice in May 2016 reiterating the rules associated with the possession and utilisation of portable X-ray generating devices. “The performance of radiological examinations outside a room fitted out for that purpose must remain the exception and be justified by vital medical needs, limited to intraoperative examinations or for patients who cannot be moved. Routine radiology practice in a dental surgery equipped with a compliant facility shall not be carried out using mobile or portable devices”. This position is consolidated by that adopted by the Heads of the European Radiological protection Competent Authorities – HERCA), for which the use of such devices should be reserved for invalid patients, for the forensic medicine sector and for military personnel in the field of action (Position statement on use of handheld portable dental X-ray equipment –HERCA, June 2014). 2.5.3 Radiation protection situation: spotlight on the CT scanner More than 900 facilities possess nearly 1,250 CT scanners. Since 1 July 2021, CT scanners come under the registration system (see point 1.3.3). In France, medical applications represent the primary source of artificial exposure of the public to ionising radiation, chiefly due to CT examinations (see chapter 1). Imaging examinations have proven their benefits for both diagnosis and treatment. The issue at stake however is to avoid examinations that are not really necessary or that offer no real benefit for the patients and the results of which could be obtained by other available, non-irradiating techniques. In order to control the increase in doses observed over these last few years, two successive dose control plans (see chapter 1) have been developed in recent years. Issued in this context, ASN resolution 2019-DC-660 of 15 January 2019 relative to quality assurance in medical imaging contributes to the control of doses by requiring operational implementation of the justification and optimisation principles. Each year, ASN conducts about twenty inspections in computed tomography, adopting a graded approach by targeting the Accident & Emergency (A&E) departments (most often shared with the radiology department) and the paediatric CT scanners because of the vulnerability of the population concerned. Numerous ESRs occur in CT examinations in the A&E departments and are caused by poor communication or organisation between the A&E staff and radiology. The inspections conducted by ASN focus in particular on the verification of proper application of the requirements defined by ASN resolution 2019-DC-0660 of 15 January 2019 relative to quality assurance in medical imaging, especially the justification of the examinations and optimisation of the procedures. The majority of the inspected departments moreover have recourse to teleradiology to ensure Out-Of-Hours (OOH) service. The activity carried out in this context also enters into the checks performed in inspections. In 2021, ASN carried out 21 inspections in the area of computed tomography. On the whole, the organisation for the examination of patients at risk (vulnerable patients, children, pregnant women, etc.) is formalised and duly followed (66% of centres) and more than half of the inspected CT scanners have a Dose Archiving and Communication System (DACS). Furthermore, the various stages in the verification of the examination requests (reception, prior analysis, validation, substitution, procedure cancellation) are well formalised (70% of centres). The medical staff however are insufficiently trained in patient radiation protection (50% of centres) and their qualification at the work station is insufficiently carried out and formalised (30% of centres). 2.5.4 Significant events reported in medical and dental radiodiagnosis 313 ESRs were reported in medical and dental radiodiagnosis: ∙ 85 in conventional radiology, of which 45 concerned women unaware of their pregnancy; ∙ 226 in computed tomography, of which 98 concerned women unaware of their pregnancy; ∙ two in dental radiology. The ESRs primarily concern women unaware of their pregnancy (143), failings in the patient management process (identity monitoring error, protocol errors, etc.) and situations of inappropriate exposure of professionals (12). Checks by the medical staff for possible pregnancy in patients must be further increased. A specific Patient safety newsletter was produced and published in September 2021 to improve the organisational measures to reduce the number of events of this type (see point 2.7). In addition, an “Experience feedback” sheet was put on line in 2021 further to an ESR reported in 2020 concerning the overexposure of a cohort of 32 patients, including 10 children, in a health care centre which had just installed a new CT scanner using spectral technology for its A&E department. The aim is to share the corrective actions put in place by the centre in order to render safe the use of a new CT scanner that employs a new technology, through proper identification of the different steps and formalising them, particularly in the quality assurance system, to prevent the recurrence of this type of event. SUMMARY ASN’s oversight in the area of computed tomography focuses essentially on observance of the principle of justif ication to avoid delivering unnecessary doses to patients. In this respect, during the inspections it conducted in 2021, ASN still f inds a lack of traceability of justification of the examinations and of the difficulties medical professionals encounter in applying the principle. The lack of training of the referring practitioners, the lack of use of the Guide to good medical imaging practices, and the lack of justification protocols for the most common procedures partly explain the fact that the justification principle is not always applied. Furthermore, the lack of availability of other diagnostic methods (MRI, ultrasonography) and of health professionals limits the replacement of irradiating procedures by non-irradiating procedures. Alongside this, ASN notes that the examination protocols are optimised, the quality controls of the medical devices are carried out at the required regulatory frequency and that the medical physics resources are appropriate for the tasks to perform. 228 ASN Report on the state of nuclear safety and radiation protection in France in 2021 07 – MEDICAL USES OF IONISING RADIATIONS
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