Objectives <p>Despite recommendations and guidelines on patient contact shielding in X-ray imaging, substantial uncertainties remain in clinical practice, particularly concerning computed tomography (CT) examinations and vulnerable groups such as pediatric and pregnant patients. This study identifies gaps in existing recommendations and offers a comprehensive statement of the actual risks and benefits associated with patient shielding.</p> Materials and methods <p>A systematic literature search was conducted using Google Scholar and PubMed, alongside current national and international guidelines. Our special report focused on patient shielding in projection radiography, interventional radiology, and CT, with special emphasis on vulnerable patient groups sensitive to radiation exposure.</p> Results <p>Current research lacks robust, evidence-based data comparing the benefits and risks of patient shielding, especially in CT. In projection radiography and interventional radiology, patient shielding offers minimal benefits and may inadvertently increase radiation exposure due to interference with automatic exposure control or necessitate repeated examinations. This issue is particularly addressed in pediatric and pregnant patients. In CT, the benefits and risks are more complex, with substantial research gaps hindering informed decision-making.</p> Conclusion <p>Traditional and generalized recommendations for patient contact shielding do not adequately account for technological advancements and individual patient needs. The use of patient shielding should be reconsidered on a case-by-case basis, guided by evidence-based research. There is an urgent need for clinical studies to assess the benefits, and in particular the risks in real-world settings, facilitating the development of precise patient-specific guidelines.</p> Key Points <p><Emphasis Type="BoldItalic">Question</Emphasis> <i>While patient shielding can increase radiation dose due to interference with automatic exposure controls, uncertainties persist regarding patient shielding in X-ray imaging practices</i>.</p> <p><Emphasis Type="BoldItalic">Findings</Emphasis> <i>There is marginal evidence of the clinical risks of patient shielding, and urgent needs exist for patient-specific evidence-based shielding guidelines</i>.</p> <p><Emphasis Type="BoldItalic">Clinical relevance</Emphasis> <i>By critically evaluating the ambiguous guidelines on patient shielding and highlighting the lack of evidence-based risks of patient shielding, this study argues for individualized, evidence-based practices to improve patient safety in clinical radiology</i>.</p>