Management of Radiation-Generating Equipment

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Loma Linda University Health maintains compliance with The Joint Commission, state, and federal requirements for radiation-producing equipment through the Management of Radiation-Generating Equipment (MaRGE) Program.  This program is administered by the Office of Radiation Safety (ORS) with an emphasis on personnel and patient safety.  

The MaRGE Program incorporates guidance from the American College of Radiology, the American Association of Physicists in Medicine, and the National Council on Radiation Protection for determining the performance standards, scope of equipment evaluations and other requirements.  Operating Policy T-61 Management of Safety of Radiation-Generating Equipment organizes this effect and details responsibilities.

ORS is responsible for all diagnostic medical physics services at all LLUH sites.  These services include commissioning of new equipment; annual physics testing and re-testing after significant repair or component replacement; patient radiation dose monitoring and calculation; shielding design and assessment; assessment of potential reportable events; preparation for, and involvement in, audits by regulatory agencies; state registration of radiation-generating equipment; training of physicians, clinical staff, and students; and consultation services.

Departments that possess radiation-generating equipment are responsible for maintaining various records such as preventive maintenance and repair records, an up-to-date inventory of radiation-generating equipment, current permits for technologists and physicians, physicist’s reports, etc.  These departments are also responsible for maintaining a library of information regarding the inspection, testing, and maintenance of equipment and systems.  This includes manuals, procedures provided by manufacturers, technical bulletins, and any other applicable information.  Departments possessing fluoroscopy equipment must also perform weekly output testing, maintain logs of patient exposure time, and report fluoroscopy cases meeting dose (or time) thresholds to ORS.  Departments must also notify ORS of any proposed additions, removals, or changes to their radiation-generating equipment inventory or rooms containing radiation-generating equipment.

For questions about the MaRGE Program, contact the Office of Radiation Safet