Reimaging Radiation Safety: A Call for Unified Practices in the Digital Imaging Era

Abstract

Radiation protection is at a crossroads in the era of digital imaging. Although radiographic modalities have made tremendous leaps in diagnostic sensitivity, they have, in turn, added new challenges in guaranteeing proper protection against radiation. Inconsistencies in exposure protocols, lack of health worker awareness, and differing utilization of dose optimization aids still undermine the dictums of justification and ALARA (As Low As Reasonably Achievable). This commentary calls upon the radiology and medical imaging community to embrace a concerted approach to radiation safety, based on international standards and informed by strong education, technology, and policy infrastructures. Such concerted practice has the potential to harmonize safety culture across health care systems and enable imaging professionals to reduce patient and occupational exposure without diminishing diagnostic effectiveness.

Keywords

radiation safety - digital imaging - dose optimization - radiology standards

Introduction

The revolution in digital imaging in medicine has revolutionized radiological diagnosis through improved image quality, time of acquisition, and the ability to perform new techniques like dual-energy computed tomography (CT), digital subtraction angiography, and postprocessing. More imaging, however, is associated with higher cumulative radiation dose exposure to both patients and physicians. Radiation protection, although acknowledged everywhere, is not equally applied, particularly in low-resource and mixed-care environments.[1]

In the present situation, digital radiography, multidetector CT, and fluoroscopy are performed with different grades of radiation protection practice. Whereas some centers employ sophisticated dose monitoring equipment and rigidly follow the International Commission on Radiological Protection (ICRP) guidelines, others fall behind in observance, which is also partly attributed to lack of training, aged facilities, or administrative negligence.[2] [3]

The Case for Unified Practices

The idea of harmonized radiation safety practice is not an aspiration—it is a reality. Radiology professionals need to adopt a harmonized approach that provides uniformity in:

• Exposure settings and technique charts

• Training and continuing education

• Utilization and interpretation of dose metrics

• Application of diagnostic reference levels (DRLs)

• Radiation incident reporting and auditing

Today, there is also considerable interinstitutional as well as intrainstitutional heterogeneity in the management of radiation safety. Exposure index (EI), deviation index (DI), and other quality parameters of digital radiographic images are usually underutilized or interpreted inaccurately. Even though IEC 62494–1 standard is available to standardize these parameters, training to use them effectively is missing in many practitioners.[4]

An integrated strategy can simplify these disparities and promote a shared objective: optimal diagnosis at the lowest practicable radiation risk.

Current Challenges in Radiation Safety

• (1) Lack of standardization between facilities

  Most imaging facilities utilize obsolete or vendor-specific protocols, which results in divergent patient exposures for identical procedures. This nonstandardization results in huge disparities in doses delivered and potentially jeopardizes patient safety.[3]

• (2) Inadequate training and awareness

  As stated by Seeram and Brennan, a large percentage of radiology technologists and doctors do not receive proper training in radiation protection, especially in subspecialty applications like pediatric imaging and interventional radiology.[2] This results in frequent failure to honor the ALARA (As Low As Reasonably Achievable) principle.

• (3) Neglect of pediatric radiation safety

  They are naturally more radiosensitive and live longer, so they have a greater lifetime risk of radiation-induced malignancies. However, dose reduction strategies like “Image Gently” protocols are not applied everywhere, especially in emergency situations where time is limited.[1]

• (4) Limited use of real-time dose monitoring tools

  Current imaging devices can integrate dose tracking and warnings against excessive cumulative exposures. Again, in most hospitals, these are disabled or not used, reducing their value in preventing risk.[5]

• (5) Variable implementation of national and international guidelines

  Organizations like the ICRP, Atomic Energy Regulatory Board (AERB) (India), American College of Radiology (USA), and World Health Organization have offered exhaustive guidelines, but their implementation is not uniform. Enforcing regulation is mostly restricted to tertiary-level hospitals, making peripheral units susceptible to radiation safety failures.[6]

A Unified Framework of Radiation Safety Practices

Dose Metrics and Standardized Protocols

Implementation of DRLs: Institutions need to regularly compare patient doses with DRLs as specified in ICRP Publication 135.[3] Periodic dose audits can assist in identifying outliers and protocol optimization.

Application of EI/DI and DAP (dose area product): These parameters provide exposure adequacy feedback and need to be included in quality assurance programs.[4]

Education and Ongoing Training

Radiation protection cannot be seen as a standalone module but as a competency that continues to need practice. Forced training sessions on radiation biology, strategies for reducing dose, and equipment optimization should be offered once a year.[2] Simulation-based training and electronic learning modules can make learning practical and accessible.

Technology-Driven Dose Optimization

New technologies present robust tools to monitor and control exposure in real time: artificial intelligence and machine learning can estimate optimal exposure settings from patient size and anatomy.[5]

Automatic exposure control and iterative reconstruction algorithms in CT scanning can minimize dose markedly without degrading image quality. Interfacing dose management software with Picture Archive and Communication System/Radiology Information System (PACS/RIS) enables cumulative dose tracking and flagging of high-risk exposures.[5]

Institutional Policies and Oversight

A strong radiation safety culture must be established institution-wide: Appointment of radiation safety officers (RSOs) who have clearly defined responsibilities. Regular radiation safety audits and risk assessments. Having incident reporting mechanisms that are nonpunitive to promote openness.[6]

Patient Communication and Consent Regarding Radiation Exposure

Radiation safety is not only about equipment and protocols—it is also about people. A vital part of the process is making sure patients, and when applicable their accompanying relatives, are aware of the radiation exposure involved in their imaging procedure. Informing them about the estimated dose before an X-ray, CT scan, or fluoroscopic procedure fosters transparency and shared decision-making. Wherever possible, a summary of the patient's cumulative dose during a hospital stay or over multiple visits should be provided. This openness not only builds trust but also supports a culture where patients are active participants in their own safety.

Implementation and Monitoring by Regulators and Hospital

To strengthen compliance with unified safety practices, hospitals and regulators can adopt practical measures such as integrating dose monitoring software into PACS/RIS systems to provide real-time feedback, making radiation safety audits a mandatory part of quality assurance, and linking compliance with safety standards to hospital accreditation. We recommend performing audits at least once a year, with additional reviews after major changes in imaging protocols or the introduction of new equipment. This regular review ensures that safety measures remain current and effective.

Radiation Safety Committees in Hospitals

In addition to having a RSO, hospitals should consider forming a multidisciplinary radiation safety committee, similar to infection control committees. Such a committee could include the RSO, radiologists, medical physicists, and clinicians from various specialties. Meeting regularly, this group would review safety policies, evaluate cumulative dose data, and coordinate staff training. A team-based approach ensures that radiation protection is addressed from multiple perspectives, making the safety net stronger for both patients and health care workers.

Global and National Viewpoints

India, through the AERB, has formulated extensive safety codes (e.g., AERB/RF-MED/SC-1 Rev.2, 2020), requiring quality assurance tests and monitoring of personnel.[6] Enforcement of these regulations is still difficult, particularly in nonaccredited diagnostic centers.

Internationally, efforts such as Image Gently, Image Wisely, and Euro Safe Imaging have become active, with dose consciousness and safety campaigns encouraged. Locally adopting these efforts, with modifications appropriate to local constraints, can fill the gap between policy and implementation.[1] [3]

Conclusion

Radiation safety in the age of digital imaging needs more than technology updates—it needs a shift in culture. The plea for harmonized practices is not for uniformity for the sake of uniformity but for consistency, effectiveness, and responsibility in safeguarding patients and professionals from avoidable radiation exposure.

Through standardization of protocols, increased training, utilization of smart technologies, and enforcement of policies, the imaging community can redefine radiation protection in directions that meet the momentum of digital transformation.

The imaging of the future will not only be sharper, but safer.

Conflict of Interest

None declared.

Acknowledgments

The authors express their gratitude to Mr. Satyam Verma and Jyoti Yadav for their invaluable insight and guidance during the writing of this manuscript.

Authors' Contributions

A.K. originated the idea, developed the introduction, and drafted the core manuscript. A.K. and S.A. collaboratively wrote relevant materials, significantly contributing to the respective sections. The manuscript was analyzed and interpreted through the collective efforts of K.S., S.K.Y., and A.M. The entire team diligently reviewed, refined, and approved the final manuscript of commentary.

• References

• 1 Strauss KJ, Kaste SC. The ALARA (as low as reasonably achievable) concept in pediatric interventional and fluoroscopic imaging: striving to keep radiation doses as low as possible during fluoroscopy of pediatric patients–a white paper executive summary. Radiology 2006; 240 (03) 621-622
• 2 Seeram E, Brennan PC. Radiation protection education and training—what are the requirements for health professionals?. Radiography (Lond) 2016; 22 (01) S7-S12
• 3 International Commission on Radiological Protection. Diagnostic reference levels in medical imaging: ICRP Publication 135. Ann ICRP 2017; 46 (01) 1-144
• 4 Samei E, Seibert JA, Andriole KP. et al. Image quality in radiology: from acquisition to perception. Radiographics 2009; 29 (02) 425-446
• 5 Kalra MK, Homayounieh F, Davoodi R. et al. Artificial intelligence in radiology: opportunities, challenges, and pitfalls. Radiographics 2020; 40 (06) 1731-1746
• 6 Atomic Energy Regulatory Board (AERB). . Code of practice for protection of persons against ionizing radiation emitted from medical diagnostic x-ray equipment. AERB/RF-MED/SC-1 (Rev. 2). Mumbai: AERB; 2020

Publication History

Article published online:
10 October 2025