Clinical Radiation Safety SWMS
Diagnostic radiology (x-ray), fluoroscopy, CT, mobile imaging, dental imaging — lead PPE, dose monitoring (OSL badge), time/distance/shielding principles, occupational dose limits (20 mSv/yr TWA over 5 yr, 50 mSv max any single yr).
SWMS variants reference your state's WHS legislation. Instant download after payment.
This SWMS covers clinical diagnostic-radiology and image-guided-procedure work in Australian hospitals, imaging clinics, day-surgery theatres, veterinary practices, and dental practices — stationary and mobile X-ray, fluoroscopy (C-arm and fixed), computed tomography, interventional cardiology and radiology, dental panoramic and cone-beam CT, and portable X-ray in operating theatres and intensive-care wards. It is written for radiographers, medical imaging technologists, sonographers supporting fluoroscopic procedures, interventional clinicians, theatre staff, dental assistants, veterinary imaging staff, and Radiation Safety Officers (RSOs) responsible for the institutional programme. Every activity in this document has been authored against ARPANSA RPS 14.1 (Safety Guide for Radiation Protection in Diagnostic and Interventional Radiology), ARPANSA RPS C-5 (Code for Radiation Protection in Planned Exposure Situations — Medical Exposure), and the binding state radiation legislation under which each facility operates.
Clinical radiation safety is governed by a dual regulatory framework that is distinct from the SafeWork Australia model-WHS framework applied to most occupational hazards. Primary statutory authority sits with the **state-level Radiation Safety Acts** — NSW Radiation Control Act 1990, VIC Radiation Act 2005, QLD Radiation Safety Act 1999, WA Radiation Safety Act 1975, SA Radiation Protection and Control Act 2021, TAS Radiation Protection Act 2005, ACT Radiation Protection Act 2006, and NT Radiation Protection Act 2004. Each jurisdiction issues user licences and premises licences, mandates appointment of a Radiation Safety Officer, and requires a site-specific Radiation Management Plan (RMP) approved by the state regulator before any ionising-radiation apparatus is used. ARPANSA codes and safety guides provide the technical standards cited by these state Acts. The model WHS framework applies at the general-duty level (Section 19 of the WHS Act) but the Hazardous Chemicals regulations in WHS Regulation Part 7.1 do not extend to ionising radiation. The occupational dose limit is **20 mSv per year averaged over 5 years with a maximum of 50 mSv in any single year**; the public dose limit is 1 mSv per year. This SWMS is designed to complement the institutional RMP and the individual user licence; it does not replace either. The governing principle throughout is ALARA — As Low As Reasonably Achievable — applied via time, distance, and shielding.
Hazards identified
12 hazards covered, sorted by priority.
Acute radiation dose to hands and torso from direct beam if an operator stays in the room during exposure without a shielded control booth or lead barrier; high-dose single-event injury including erythema and long-latency cancer risk.
Chronic scattered-radiation dose accumulating over a career, particularly for interventional cardiologists and radiologists; cataract (lens-of-eye exposure) and increased leukaemia risk.
Low-level continuous dose from housing leakage above ARPANSA limits if equipment compliance testing is overdue or housing has been damaged in service.
Foetal exposure above 1 mSv over the declared pregnancy causing stochastic risk; duty to manage worker notification, task reassignment, and dose review.
Exceedance of 20 mSv/year or 50 mSv single-year limit, triggering mandatory investigation, potential licence suspension, and employee health review.
Unintended patient dose exceeding the clinical indication; notifiable incident to the state regulator and potential coronial review if patient harm occurs.
Reduced protection factor from cracked lead, torn seams, or undersized aprons that do not cover the worker's lateral torso during fluoroscopic work.
Crush from C-arm or mobile-X-ray unit drift, electrical shock from damaged cabling, and trip hazard from cabling across theatre floors.
Uncontrolled radiation output if a fault condition prevents beam termination; modern equipment has watchdog timers but older equipment may not.
Inability to demonstrate occupational dose compliance if badges are not worn, are lost, or are not exchanged on schedule; breach of licence conditions.
Unintended public or ancillary-staff exposure if theatre runners, cleaners, or visiting clinicians enter during beam-on without dosimetry or shielding.
Unshielded output, incorrect collimation, or leakage above limits if post-service compliance testing is not completed before clinical use.
Control measures
Hierarchy-of-controls order: elimination → substitution → isolation → engineering → administrative → PPE.
- 1Appointment of a licensed Radiation Safety Officer (RSO) as required under the applicable state Radiation Safety Act, with documented authority over the site RMP, equipment acceptance, and incident reporting.
- 2Current state-issued user licence for every clinician, radiographer, medical imaging technologist, and authorised assistant operating ionising-radiation apparatus, and a current premises licence for the imaging facility.
- 3Site-specific Radiation Management Plan approved by the state regulator, reviewed annually, and available at every controlled area. This SWMS complements but does not replace the RMP.
- 4Engineering control — lead-lined room construction per AS/NZS 2982 for permanent installations; shielded control booths with leaded glass viewing windows at every fluoroscopy, CT, and general-radiography suite; mobile lead screens for interventional theatres.
- 5Time, distance, and shielding as the three non-negotiable exposure controls (ALARA). Pulsed fluoroscopy default on every C-arm; inverse-square-law distance of at least 6 feet (1.8 m) from the primary beam for all personnel not directly required at the patient; lead-screen interposition between primary-beam workers and support staff.
- 6Lead PPE — lead-rubber apron minimum 0.25 mm lead equivalent for diagnostic radiography and 0.35 mm lead equivalent for fluoroscopy and interventional work; thyroid shield for all fluoroscopic exposure and for primary-beam radiographers; leaded glasses 0.5 mm lead equivalent for interventionalists; lead gloves for work near the primary beam.
- 7Lead-PPE inspection and fluoroscopic integrity check every 6 months and after any damage; any garment with a crack, tear, or separated seam larger than 5 mm² is withdrawn from service and replaced.
- 8Personal dosimetry — OSL or TLD whole-body dosimeter worn at collar level outside the lead apron for every occupationally exposed worker, exchanged monthly or quarterly per the ARPANSA Personal Radiation Monitoring Service schedule. Extremity (ring) dosimetry for interventionalists and staff with potential high hand dose. Lens-of-eye dosimetry where eye dose may approach 20 mSv/year.
- 9Dose-limit management — occupational whole-body effective dose limit 20 mSv/year averaged over 5 years with a maximum of 50 mSv in any single year; lens of eye 20 mSv/year; skin and extremity 500 mSv/year; public 1 mSv/year. Dose reports reviewed monthly by the RSO and any exceedance investigated within 7 days.
- 10Pregnancy declaration procedure — voluntary written declaration to the RSO triggers dose review, task reassignment where needed to keep additional foetal dose below 1 mSv over the declared pregnancy, and additional dosimetry at the abdomen.
- 11Annual equipment compliance testing by an ARPANSA-approved or state-approved test service covering output consistency, beam quality, collimation, leakage, and automatic-exposure-control performance. Certificates retained and provided to the regulator on request.
- 12Post-service recommissioning — any equipment returned to service after repair, relocation, or software upgrade receives a post-service compliance test before clinical use; commissioning record retained with the RMP.
- 13Radiation warning signage per AS 1319 and the international trefoil symbol at every controlled-area entry; illuminated 'Do Not Enter — X-ray in Progress' lights at theatre doors; door interlocks where specified by the RMP.
- 14Staff training and refresher — pre-employment radiation awareness training for all staff entering controlled areas, and annual refresher for licensed users covering dose limits, equipment changes, and incident learnings. Competency records retained for 30 years.
- 15Incident reporting — any suspected over-exposure, equipment malfunction affecting dose, lost dosimeter, or breach of RMP reported to the RSO within 24 hours and to the state regulator within the statutory notification period (typically 24-48 hours depending on jurisdiction).
- 16Emergency response — beam-off procedure, theatre evacuation sequence in the event of equipment fault preventing beam termination, and post-incident patient and staff dose reconstruction performed by a qualified medical physicist.
Applicable Codes of Practice
Primary technical guide governing occupational and patient dose management in diagnostic and interventional practice; cited by state radiation Acts but not an SWA model Code of Practice.
Binding code where adopted by state legislation; sets out the ALARA principle, justification, and optimisation obligations for medical exposure.
Sets out the occupational and public dose limits applied throughout this SWMS; referenced by every state Radiation Safety Act.
Primary statutory authority in NSW — user and premises licensing, RSO appointment, RMP requirements, compliance testing, and incident notification.
Victorian equivalent establishing user and management licensing, RSO appointment, and RMP approval by the Department of Health.
Queensland equivalent; similar licensing, RSO, and RMP regime administered by Queensland Health Radiation Health Unit.
Technical standard for lead-lined room design, shielding calculations, and controlled-area specifications.
Who this is for
- →Radiographers and medical imaging technologists operating general X-ray, fluoroscopy, CT, and mobile-X-ray in hospitals and imaging clinics.
- →Interventional radiologists, cardiologists, vascular surgeons, and theatre teams performing image-guided procedures.
- →Dental practitioners and dental assistants operating intraoral, panoramic, and cone-beam CT equipment.
- →Veterinary radiographers and assistants operating small-animal and large-animal diagnostic X-ray.
- →Radiation Safety Officers (RSOs), medical physicists, and practice managers responsible for the institutional radiation programme, RMP, and licence compliance.
What you receive
- ✓Editable Microsoft Word (.docx) document delivered within 24 hours of payment.
- ✓Title page with facility name, ABN, RSO name and licence number, premises licence number, and revision date fields.
- ✓Signed approval block for facility owner, Chief Medical Officer or clinical lead, and Radiation Safety Officer.
- ✓Hazard register with the 12 hazards above, each with consequence, inherent risk, controls, and residual risk scored on a 5x5 likelihood-consequence matrix.
- ✓Hierarchy-of-control measures cross-referenced to ARPANSA RPS 14.1 and the applicable state Radiation Safety Act.
- ✓Personal dosimetry register template and lead-PPE inspection log aligned to the ARPANSA Personal Radiation Monitoring Service schedule.
- ✓Pregnancy declaration procedure template and confidential foetal-dose tracking record.
- ✓Annual equipment compliance-test schedule and post-service recommissioning log.
- ✓State-by-state legislation variance table (NSW, VIC, QLD, WA, SA, TAS, ACT, NT) covering user licensing, RSO appointment, and RMP obligations.
- ✓Incident notification template, emergency-response procedures for equipment fault, and 30-year dosimetry record retention guidance.
Worked example
A cardiac catheterisation laboratory in a suburban Sydney private hospital is scheduled for a three-hour percutaneous coronary intervention using a fixed C-arm fluoroscope. The procedure team comprises an interventional cardiologist, a second cardiologist, a scrub nurse, a circulating nurse, and a radiographer. Before the procedure the radiographer confirms that annual ARPANSA-approved compliance testing is current (certificate dated 4 months ago), the C-arm defaults to pulsed fluoroscopy at 15 pps, and the room trefoil warning light is functional. Every team member wears a 0.5 mm lead-equivalent wrap-around apron, a 0.5 mm thyroid shield, and a collar-level OSL dosimeter; both cardiologists wear leaded glasses and ring dosimeters. A ceiling-suspended lead acrylic screen is positioned between the primary operator and the patient's pelvis. The circulating nurse stands behind a mobile lead shield at 6 feet from the table. During the procedure total fluoroscopy time is 42 minutes and cumulative air-kerma at the reference point is recorded at 1.8 Gy. Post-procedure the radiographer logs the fluoroscopy time to the patient record, confirms all dosimeters remain in date, and returns the lead aprons to the storage rack. The monthly OSL report dispatched by ARPANSA records the primary operator's collar dose at 0.12 mSv — well within the 20 mSv/year occupational limit. Lead-apron fluoroscopic integrity check is scheduled for the following month.
Related legislation
- NSW Radiation Control Act 1990 and Radiation Control Regulation 2013 — user licensing, premises licensing, RSO appointment, RMP, compliance testing, incident notification.
- Victorian Radiation Act 2005 and Radiation Regulations 2017 — management licence, use licence, and RSO provisions administered by the Department of Health.
- Queensland Radiation Safety Act 1999 and Radiation Safety Regulation 2021 — licensing and RSO provisions administered by Queensland Health.
- Western Australian Radiation Safety Act 1975 and Radiation Safety (General) Regulations 1983 — licensing and RSO provisions administered by the Radiological Council.
- South Australian Radiation Protection and Control Act 2021 — modernised licensing framework administered by the EPA.
- Work Health and Safety Act 2011 (NSW) — Section 19 primary duty of care applying at the general-duty level alongside the state radiation legislation.
- Privacy Act 1988 (Cth) and Health Records Act 2001 (Vic) — patient dose records and occupational dosimetry records retention.
- ARPANSA Act 1998 (Cth) — establishment of the Australian Radiation Protection and Nuclear Safety Agency and the Personal Radiation Monitoring Service.
Frequently asked questions
Does this SWMS replace my institutional Radiation Management Plan?
No. The Radiation Management Plan is a statutory document mandated by the applicable state Radiation Safety Act and must be approved by the state regulator before any ionising-radiation apparatus is used at the facility. This SWMS complements the RMP by providing a task-level hazard and control register that aligns with the RMP and meets general WHS duty-of-care requirements. Use the two documents together.
Why is radiation safety not governed by the model WHS framework?
Ionising radiation is regulated separately under state Radiation Safety Acts that pre-date and sit alongside the model WHS framework. The Hazardous Chemicals provisions in WHS Regulation Part 7.1 do not extend to ionising radiation, and most of the Codes of Practice referenced in this document are ARPANSA codes rather than SWA model Codes. The general-duty provisions of the WHS Act still apply, which is why this SWMS is the right document to demonstrate due diligence alongside the RMP.
What dose limits apply to my staff?
Occupational effective dose is limited to 20 mSv per year averaged over 5 consecutive years, with a maximum of 50 mSv in any single year. Lens-of-eye dose is limited to 20 mSv per year (reduced from 150 mSv in the 2014 ARPANSA update). Skin and extremity dose is limited to 500 mSv per year. Members of the public are limited to 1 mSv per year. These limits are set out in ARPANSA RPS C-1 and adopted by every state Radiation Safety Act.
Do we need OSL dosimetry for every worker entering the imaging area?
Dosimetry is required for every worker likely to receive an annual dose exceeding 1 mSv (the dose constraint for members of the public). In practice this means every radiographer, interventionalist, theatre team member, dental staff member, and veterinary imaging worker, but may not extend to occasional visitors or cleaners whose access is brief and outside beam-on periods. The RSO makes the final determination based on task profile and dose history.
How do we handle a pregnancy declaration?
The declaration is voluntary and confidential. Once declared, the RSO reviews the worker's task profile and dose history, reassigns tasks where needed to keep additional foetal dose below 1 mSv over the remaining pregnancy, and arranges additional dosimetry at the abdomen if continued duties warrant it. The declaration procedure is included in the SWMS and aligns with ARPANSA RPS C-1 guidance.
What happens if an over-exposure or equipment fault occurs?
Suspected over-exposure or equipment malfunction affecting dose is reported to the RSO within 24 hours and to the state regulator within the statutory notification period (24-48 hours depending on jurisdiction). A qualified medical physicist performs dose reconstruction, the equipment is isolated and inspected, and a corrective-action report is prepared. Patient over-exposure may also trigger clinical governance and open-disclosure obligations to the patient.