Checklist template

Radiation and anesthetic gas safety for veterinary hospitals

A ready-to-use checklist with 112 items in 6 sections, covering Protective equipment, Dosimetry, Scavenging, Leak checks, Training, Records. Use it as-is in Bindy, or adapt it to your own standards in minutes.

  • 6 Sections
  • 112 Items
  • 95 Yes / No checks
  • 6 Scored ratings
  • 125 Points

Use this template How audits work

1. Protective equipment 20 items

  1. A lead apron is available for each person who may be in the X-ray room during an exposure Yes / No 1 pt
  2. A thyroid collar is available for each apron Yes / No 1 pt
  3. Lead gloves or mitts are available in at least 2 pairs Yes / No 1 pt
  4. Lead glasses are available where company policy requires them Yes / No 1 pt
  5. Aprons are hung on a rack or hangers and are not folded Yes / No 1 pt
  6. Gloves are stored open on a rack or over inserts, not flattened Yes / No 1 pt
  7. Each apron, collar and pair of gloves carries an identification number Yes / No 1 pt
  8. Aprons examined during the visit show no cracks, tears or sagging lead Yes / No 1 pt
  9. Gloves examined during the visit show no cracks or holes Yes / No 1 pt
  10. Protective garments were screened by radiograph or fluoroscopy within the last 12 months Yes / No 1 pt
  11. Date of the last screening of lead garments Date
  12. Garments that failed screening were removed from service Yes / No 1 pt
  13. Sandbags, foam wedges, troughs and tape are available for hands-free positioning Yes / No 1 pt
  14. A mobile or fixed lead shield protects the operator of the dental X-ray unit Yes / No 1 pt
  15. Lead gloves are worn on the hands, not laid over them, when manual restraint is unavoidable Yes / No 1 pt
  16. The collimator light works on each X-ray unit Yes / No 1 pt
  17. Only the people needed for the study stay in the X-ray room during an exposure Yes / No 1 pt
  18. A radiation warning sign is posted on each door to the X-ray room Yes / No 1 pt
  19. Lead aprons in service Number
  20. Condition of radiation protective garments Rating
    • Intact, stored correctly and screened 5 pts
    • Intact but stored badly or screening overdue 3 pts
    • Damaged garments in use 1 pt

2. Dosimetry 19 items

  1. Each employee who works in the X-ray room is assigned a personal dosimeter Yes / No 1 pt
  2. Dosimeters carry the wearer's name and the current wear period Yes / No 1 pt
  3. Dosimeters are worn at collar level outside the apron, or as the dosimetry provider instructs Yes / No 1 pt
  4. An employee seen taking radiographs during the visit was wearing a dosimeter Yes / No 1 pt
  5. Dosimeters are stored on a board outside the X-ray room when not worn Yes / No 1 pt
  6. A control dosimeter is kept on the storage board Yes / No 1 pt
  7. Dosimeters stay at the hospital and are not taken home or shared Yes / No 1 pt
  8. Dosimeters are exchanged on the provider's schedule Yes / No 1 pt
  9. Date of the last dosimeter exchange Date
  10. Dose reports are reviewed and initialed by the radiation safety officer Yes / No 1 pt
  11. Each employee can see their own dose report Yes / No 1 pt
  12. No report in the last 12 months shows a dose above the investigation level set by company policy Yes / No 1 pt
  13. Any reading above the investigation level has a written follow-up Yes / No 1 pt
  14. Employees who declare a pregnancy are offered a fetal dosimeter and a change of duties, per company policy Yes / No 1 pt
  15. Extremity or ring dosimeters are issued where hands may be near the beam Yes / No 1 pt
  16. Dosimeters are returned and service is cancelled when an employee leaves Yes / No 1 pt
  17. Employees currently issued a dosimeter Number
  18. Name of the radiation safety officer Short text
  19. Dosimeter use Rating
    • Worn by everyone, exchanged on time 5 pts
    • Worn but exchanges late 3 pts
    • Not worn consistently 1 pt

3. Scavenging 20 items

  1. Each anesthesia machine is connected to an active scavenging system or a charcoal canister Yes / No 1 pt
  2. The scavenging hose from each machine runs unkinked to the exhaust or canister Yes / No 1 pt
  3. Active scavenging suction is on when the machine is in use Yes / No 1 pt
  4. Each charcoal canister is weighed before the first case of the day Yes / No 1 pt
  5. The weight is written on each charcoal canister or its log Yes / No 1 pt
  6. Canisters are replaced at the weight gain stated by the manufacturer Yes / No 1 pt
  7. Canister exhaust holes are not blocked by the surface the canister rests on Yes / No 1 pt
  8. The pop-off valve of each machine connects to the scavenging line Yes / No 1 pt
  9. Induction chambers are connected to scavenging Yes / No 1 pt
  10. Induction chambers are flushed with oxygen into the scavenging before the lid is opened Yes / No 1 pt
  11. Mask inductions are limited to cases where the veterinarian has ordered them Yes / No 1 pt
  12. Non-rebreathing circuits are connected to scavenging Yes / No 1 pt
  13. Endotracheal tube cuffs are inflated to seal the airway before the vaporizer is turned on Yes / No 1 pt
  14. After the vaporizer is turned off, patients stay on oxygen in the circuit for the time set by company policy before disconnection Yes / No 1 pt
  15. Patients recover in a ventilated area, not in a closed room with staff Yes / No 1 pt
  16. Passive scavenging exhaust vents outdoors away from air intakes and windows Yes / No 1 pt
  17. Supply and exhaust air vents in the surgery and dental rooms are unblocked Yes / No 1 pt
  18. Scavenging is available at the dental station Yes / No 1 pt
  19. Anesthesia machines in service Number
  20. Scavenging of waste anesthetic gas Rating
    • Every machine scavenged and canisters tracked 5 pts
    • Scavenged but canisters not weighed 3 pts
    • A machine in use without scavenging 1 pt

4. Leak checks 18 items

  1. The high-pressure side (cylinder yoke, hoses, flowmeter) is checked for leaks each time a cylinder is changed Yes / No 1 pt
  2. The leak test is repeated after each change of circuit or absorbent canister Yes / No 1 pt
  3. The leak test done in front of the inspector held pressure Yes / No 1 pt
  4. Connections between the vaporizer, the fresh gas outlet and the circuit are tight with no audible hiss Yes / No 1 pt
  5. Breathing hoses have no cracks at the corrugations Yes / No 1 pt
  6. Vaporizer fill caps are tight and their seals are intact Yes / No 1 pt
  7. Carbon dioxide absorbent canister gaskets are seated and free of granules Yes / No 1 pt
  8. Employees asked could explain how to locate a leak with soap solution or a leak detector Yes / No 1 pt
  9. Vaporizers are filled with a keyed filler or anti-spill adapter Yes / No 1 pt
  10. Vaporizers are filled at the end of the day or when few staff are present Yes / No 1 pt
  11. Anesthetic bottles are capped tightly when not in use Yes / No 1 pt
  12. A spill kit or absorbent for liquid anesthetic is in the surgery area Yes / No 1 pt
  13. Employees asked could describe what to do after a liquid anesthetic spill Yes / No 1 pt
  14. No odor of isoflurane or sevoflurane is noticeable in the surgery, dental or recovery areas during the visit Yes / No 1 pt
  15. Date of the last waste anesthetic gas measurement Date
  16. Anesthesia machines were serviced by a qualified technician in the last 12 months Yes / No 1 pt
  17. Waste gas levels were measured by badge or meter where company policy requires monitoring Yes / No 1 pt
  18. Leak control on anesthesia machines Rating
    • Daily tests recorded and passed 5 pts
    • Tests done but not recorded 3 pts
    • Tests not done or leaks found 1 pt

5. Training 16 items

  1. Each employee who takes radiographs has completed radiation safety training Yes / No 1 pt
  2. Radiation safety training is refreshed at the interval set by company policy Yes / No 1 pt
  3. Employees asked could state the three protections: time, distance and shielding Yes / No 1 pt
  4. Employees asked said they leave the room or step back at least 6 ft (2 m) when the patient is sedated and positioned Yes / No 1 pt
  5. Sedation is used to avoid manual restraint unless the veterinarian records a medical reason Yes / No 1 pt
  6. No part of a person's body is in the primary beam on 10 recent radiographs reviewed Yes / No 1 pt
  7. Radiographs out of 10 showing a hand or fingers Number
  8. Employees below the minimum age set by local regulation do not take part in radiography Yes / No 1 pt
  9. Each employee who runs anesthesia has been trained on the machine check and scavenging Yes / No 1 pt
  10. Employees asked could explain how to weigh and replace a charcoal canister Yes / No 1 pt
  11. Pregnant employees have been informed of the options for radiography and anesthesia duties Yes / No 1 pt
  12. Safety data sheets for the inhalant anesthetics in use are accessible to staff Yes / No 1 pt
  13. New hires complete imaging and anesthesia safety training before working unsupervised Yes / No 1 pt
  14. Training covers the dental X-ray unit and handheld units where used Yes / No 1 pt
  15. Relief veterinarians and technicians are shown the hospital's radiation rules on their first shift Yes / No 1 pt
  16. Staff knowledge of radiation and waste gas precautions Rating
    • Correct answers from everyone asked 5 pts
    • Partly correct 3 pts
    • Unaware of precautions 1 pt

6. Records 19 items

  1. Each X-ray unit is registered with the authority as required by local regulation Yes / No 1 pt
  2. The registration certificate is posted or on file Yes / No 1 pt
  3. Each X-ray unit was inspected or calibrated at the interval required by local regulation Yes / No 1 pt
  4. Date of the last X-ray unit inspection Date
  5. Deficiencies from the last X-ray unit inspection have been corrected Yes / No 1 pt
  6. A radiation safety officer is named in writing Yes / No 1 pt
  7. Written radiation safety rules are posted in the X-ray room Yes / No 1 pt
  8. The radiography log names the people present for each exposure Yes / No 1 pt
  9. Dose reports are kept for the period required by local regulation Yes / No 1 pt
  10. Lead garment screening results are on file by identification number Yes / No 1 pt
  11. Waste anesthetic gas measurement results are on file with the date and the area measured Yes / No 1 pt
  12. The radiation safety program was reviewed in writing in the last 12 months Yes / No 1 pt
  13. Service reports for anesthesia machines and vaporizers are on file Yes / No 1 pt
  14. Training records list the employee, the date and the topic Yes / No 1 pt
  15. Exposure incidents and anesthetic spills are recorded on the incident log Yes / No 1 pt
  16. Corrective actions from the previous radiation and anesthetic gas inspection have been completed Yes / No 1 pt
  17. Name of the person interviewed Short text
  18. Overall control of radiation and anesthetic gas hazards Rating
    • Shielding, dosimetry and scavenging all in order 5 pts
    • Gaps in records or upkeep only 3 pts
    • Staff exposed by damaged lead, missing dosimeters or unscavenged machines 1 pt
  19. Hazards found and corrective actions required Comments

About this template

This checklist is part of the Bindy template library. Yes / No checks score 1 point when met; ratings score the points shown for each option. The overall score is the percentage of points earned, with N/A answers excluded. In Bindy you can add photos, assign corrective actions, require sign-off and compare results across sites.

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