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Medical Director
Radiology IM&T Systems Manager
Radiology IM&T Systems Manager
Medical Director, Primary Care
20 January 2014
01 January 2014
20 January 2016


1.1 This procedure is intended to complement the NHS Fife PACS Policy (GP/P3).


2.1 This procedure applies throughout NHS Fife.



3.1 It is the responsibility of the local system manager (Radiology IM&T Systems Manager) for the day-to-day running of PACS and to ensure all problems are reported, resolved within the appropriate timescales, and to ensure errors are corrected timeously.



4.1 Support

4.1.1 The first point of contact for support between the hours of 9:00 am and 5:00 pm Monday to Friday is the Fife PACS team.  Outwith those hours, the on call radiographer can be contacted if the problem is such that it needs to be escalated to the supplier.


4.2 Patient Identification

4.2.1 In line with national eHealth strategy, the patient identifier is the CHI (Community Health Index) number.  In instances where a patient does not have a CHI number, perhaps because of their residential status if outwith Scotland, then a unique temporary ID will be generated from the Radiology Information System (RIS) and that number will be attached to the patient’s images.  In instances where the RIS is not available, a temporary ID comprising the patient’s date of birth and initials will be used and reconciled appropriately when the system is available again.


4.3 Data Sharing

4.3.1 All studies captured on the local archive are automatically sent to the national archive in line with national strategy, to allow emergency or specialist treatment in other Scottish health boards and to reduce the need for repeat examinations.

4.3.2 If studies need to be sent to or from other health boards outwith Scotland then the PACS team should be contacted to provide advice and assistance.


4.4 System Access

4.4.1 Access to PACS will only be granted to staff who have a clinical requirement to view images.  Access is granted by completion of the eHealth System Access Request Form which is available on the NHS Fife Intranet.  The completed form, which must be authorised by the requester’s line manager, is sent from eHealth to the PACS team and if satisfied that the requester meets the criteria to gain access to the system, a user account will be created.

4.4.2 User accounts will be reviewed on a regular basis and inactive accounts will be suspended.

4.4.3 The PACS team must be informed immediately when staff no longer have a legitimate right to access the system for example following termination of employment or a change of clinical responsibilities. This information should be passed to the PACS team by the appropriate line manager prior to, or immediately following, removal of access rights for the member of staff.


4.5 Data Errors

4.5.1 Inevitably there will be situations where amendments to images or related data will be required for example:

  • The image contains incorrect anatomical references.
  • The image has been wrongly identified.
  • The image was captured at time of RIS system downtime therefore temporary patient ID applied.
  • The image(s) were merged with other patient’s images.

4.5.2 It will be the local system manager’s responsibility to introduce a system to allow the necessary correction to be made to image data and to ensure that all changes are reflected across the system, including the central archive.  The operator responsible for the capture of the images must be able to communicate the nature of the fault and the action required for remedy to the local system manager. A permanent record of the communication and the corrective action taken should be kept locally.

4.5.3 The clinician responsible for the image will be required to assess the potential impact of the initial error and the necessary action required to inform other clinicians who may have accessed the image prior to the corrective action.


4.6 Replication of Digital Images

4.6.1 Permission must always be sought from the PACS team for replication of digital images and use of any other method is prohibited, whether by electronic or manual methods.



5.1 Risks and incidents are recorded using the Datix Reporting System.  Any clinical incidents occurring as a result of a PACS failure are brought to the attention of the PACS Clinical Advisory Group.



6.1 Please follow link to eHealth Systems Access Request Form.  The PACS Data Correction Form is in Appendix 1:


  • Data Protection Act 1998/Access to health Records policy Act 1990
  • GP/C9 NHS Fife Confidentiality Policy
  • GP/I5 NHS Fife Information Security Policy
  • GP/P2 NHS Fife Password Policy
  • GP/B2 NHS Fife Broadband Remote Access Policy
  • GP/I4 NHS Fife eHealth Procurement Policy and Procedure
  • NHS Scotland Service Level Agreement Summary