Wow…this has been an exhaustive radiology journey and we're entering the homestretch as we explore the final entries in "The 'Sweet 16' Of Radiology Violations." Discussing the most frequent issues I see during my visits to Dental offices in an earlier post ("Oops! Are You Exposed?"), I did not want to overlook these less-common, but still critical compliance violations. Let's face it, ANY violation carrying ANY fine or penalty is more than you want for your practice!
As every good Dentist knows, just because you can't readily see it…it doesn't mean a problem doesn't exist! Ignorance of the law is no longer a viable defense in Radiology Compliance violations. Knowing your vulnerabilities and becoming proactive can protect you and your practice investments. So, let's take a look at where YOU might have left yourself open!
I highly recommend every Dental practice put into place central tracking for every credential for every team member – from the Dentist to the Dental Assistants. It is a violation of the law for Dental Assistants with expired credentials to take X-rays, just as it would be for a Dentist to practice with an expired license. Stay on top of your credentials, as well as those of your staff. Even though it is your employee’s responsibility to look after their own credentials you, as the supervising Dentist (owner or associate), can still be held accountable for lack of adequate supervision when Dental Hygienists’ and Dental Assistants’ credentials lapse and they continue to perform their duties.
Technique charts are a reference tool that should be used in Dental offices to indicate the length and amount of X-ray exposures. They are specific to each make and model of X-ray machine, so simply posting a chart that you obtained from your buddy down the road will not suffice. Not only are technique charts specific to each make and model, but they need to outline the parameters your staff actually employ.
Posting inaccurate charts is like posting a big fat (white) lie on your operatory walls. Technique chart issues are relatively small issues when compared with other matters in the office. However, if you are striving for excellence within your practice, then you know that the beauty is in the details.
Many states do not require radiation warning signs be posted when X-ray machines are under constant supervision. However, control switches need to be labeled, so they are not mistaken for light switches and children’s wall-mounted toys. Though many states do not require the posting of pregnancy warning signs, I strongly encourage Dentists post them to limit their liability.
Periodic testing of X-ray machines is required in most areas. Calibration tests, known as Equipment Performance Evaluations (EPE), should be conducted upon installation and as indicated by your state’s particular regulations. These tests are often provided by Dental suppliers to evaluate timer accuracy, exposure reproducibility, linearity, KVP, exposure limits, tube stability and proper collimation.
In a nutshell, this is a quality control test. Maintain your records as required (NRC is 3 years, many states are 4-6 years). Just to be safe, keep your records for 10 years to meet the most lengthy time requirements and yet avoid becoming a pack rat.
PROCESS OF TAKING X-RAYS
When taking X-rays, your staff must be able to have direct sight and sound communication with your patient while the staff member is at least 6 feet away from the cone of the X-ray machine. Get out your tape measure and measure the distance from your X-ray cone in normal positions to the control switch. If less than 6 feet, consider installing switches on flexible cords. Also consider employee positioning and their ability to see the patient from a ‘point-of-cover’ (to throw in a little police lingo, after all I am the Tooth Cop).
INVENTORY OF X-RAY MACHINES
When you obtain a new X-ray machine or if you donate one to a local free clinic – basically, if you make any changes to the inventory of your machines – you must notify your state authority, in writing, of the make, model and serial number of the new equipment.
Additionally, you must notify them of where your old equipment will be transferred (location), as the government tracks the location of all radioactive equipment. If an X-ray machine is included on your official equipment inventory you can be held accountable for its disposition. Now, it is not likely your X-ray machine will turn up in a terror investigation, but what if it did and you did not disclose the sale or donation of that machine? Control your liability and ensure your compliance – keep your state informed of your actual, on-site inventory.
Last, but certainly not least, some states mandate quality control measures to periodically test your X-ray machines for accuracy, if only on a limited scope and scale. Do not take test X-rays on a human being, as it is an unlawful use of your equipment. X-ray exposure is a "prescription-only" procedure. Like administering, dispensing or prescribing antibiotics and other medications, X-rays must be accompanied by a Doctor’s order. Dentists and physicians cannot order tests for or prescribe ANYTHING for non-Dental (non-diagnostic) purposes. To ensure the continuing quality control of your X-ray machines you can purchase a step wedge and X-ray the step wedge to your heart’s content.
While none of these things in and of themselves seem like such a big deal, compounded as multiple violations along with the increasingly stiff fines assessments and sanctions, it can turn into a REALLY big deal! Regardless of your particular approach to compliance, whether you go the DIY route, hire a compliance specialist or just choose to ignore it until it becomes a problem, it's important for you to realize that at some point an "out of sight-out of mind" issue you will be FORCED to deal with!
In any event it’s your call. There is no wrong decision about how to handle compliance, manage risks and control your liability, so long as you can live with the consequences of your decision. I recommend for Dentists to be proactive about their compliance efforts, as (I believe) to stick your head in the sand like an ostrich will prove to penny-wise and pound-foolish. No Dental office is in 100% compliance with government regulations. However, as a continuum, I would rather see every office at more of an 80-90% rather than a 10-25%… which is all too common. You know what I call those twenty-five percenters? I call them Target Rich Environments (another law enforcement term). Is your office a Target Rich Environment?
Notice: This is not an exhaustive list of compliance considerations. Always reference your state’s regulations and bear in mind there may be more than one set of state standards. Your state radiation board and Dental board are two common sources for safety and compliance standards. The OSHA Ionizing Radiation Standard (29 CFR 1910.1096) is also very relevant to Dental offices.