IntroductionRadiographers in clinical imaging pathways ensure regulatory compliance by justifying X-ray requests, optimising exposure, and communicating urgent findings. In Australia, adherence to Australian regulatory directives is crucial for patient safety, particularly in Emergency Departments (EDs) where immediate radiologist report or guidance may be unavailable. This study explores whether Australian radiographers working within regulatory compliance of justification, optimisation and Preliminary Image Evaluation (PIE) in the ED contribute to improving patient safety? MethodsIn a retrospective blinded single-phase study, 28 radiographers reviewed 50 cases of single extremity trauma in the ED Fast-Track (FT) pathway. Data analysis assessed compliance with regulatory directives, evaluating justification, optimisation, and accuracy of Preliminary Image Evaluations (PIE) against established standards. ResultsJustification: Radiographers found 67.8 % (n = 881) of X-ray requests compliant and 32.2 % (n = 419) non-compliant. Optimisation: Participants optimised referrals by correcting anatomical selection (52.0 %, n = 676), adjusting the number of images (11.6 %, n = 151), or both (17.5 %, n = 227). PIE: Radiographer PIE demonstrated a mean sensitivity of 94.7 % (CI: 92.9 %–96.6 %), specificity of 89.6 % (CI: 87.0 %–92.2 %), and accuracy of 92.7 % (CI: 91.6 %–93.8 %). The average Positive Predictive Value (PPV) was 93.2 % (CI: 92.0–94.9 %), the Negative Predictive Value (NPV) was 91.9 % (CI: 90.2–95.0 %), and Cohen’s Kappa inter-rater reliability median was K = 0.85, with an average result of K = 0.85 (range: K = 0.74 to K = 0.96). ConclusionIn this study, radiographer compliance with regulatory standards for justification, optimisation, and PIE is high but not fully consistent. When radiographers adhere to regulations, there is potential to improve patient safety. Collaborative compliance between radiologists, referrers, and radiographers within the ED FT pathway could further improve patient safety outcomes. Additional research, including prospective studies, is necessary to further evaluate radiographer compliance in the ED FT pathway. Implications for practiceRadiographers are professionally obligated to follow Australian regulatory directives for safe medical radiation practice, guided by imaging protocols. Timely and accurate PIE by radiographers can enhance patient safety in ED.