QR Code Phishing Incident Response Checklist for Fluoroscopy Procedure Images

QR Code Phishing Incident Identification

What to look for

• Unexpected QR codes embedded in fluoroscopy procedure images, overlays, or export screens that do not match standard templates or workflow.
• Stylistic inconsistencies (font, placement, size), pixelation, or misaligned overlays that could indicate tampering and threaten fluoroscopy image integrity.
• QR codes that resolve to shortened links, mismatched domains, or login prompts—classic signs of a QR code malicious payload.
• Image metadata anomalies (e.g., timestamps, device IDs, overlay flags) suggesting post-acquisition modification.
• Staff reports of certificate warnings, forced downloads, or mobile redirection after scanning.

Initial triage

• Do not scan suspicious QR codes; if already scanned, stop interacting and capture the device state.
• Isolate affected workstations or mobile devices from the network if safe for patient care.
• Record who discovered the issue, when, where, and which systems were involved to support incident evidence preservation.
• Preserve original images and related files to maintain fluoroscopy image integrity before any edits or exports.

Decision points

• If clinical safety is at risk, prioritize patient care and switch to trusted backup workflows.
• If malicious indicators are present, proceed to Immediate Incident Response and escalate per your IT security notification protocol.

Immediate Incident Response

Containment (first 15–30 minutes)

• Disconnect or quarantine impacted endpoints and remove untrusted QR imagery from active displays where feasible.
• Block observed domains, IPs, and URLs at email, proxy, DNS, and firewall layers to halt the phishing URL analysis path attackers rely on.
• Disable compromised accounts, revoke tokens, and enforce MFA resets if any credentials were entered.
• Notify the security operations team immediately using sanctioned channels defined in your IT security notification protocol.

Stabilization (first hour)

• Freeze relevant logs (endpoint, PACS/RIS, browser, proxy, DNS) and preserve images for analysis.
• Document all actions, timestamps, and handlers to support chain-of-custody and later malware forensic investigation.
• Coordinate with clinical leadership to maintain imaging throughput using trusted sources only.

Evidence Collection

Preserve with integrity

• Secure original fluoroscopy images and associated files; compute cryptographic hashes to verify ongoing fluoroscopy image integrity.
• Capture screenshots of the suspicious QR code in context, plus any on-screen prompts or warnings.
• Export relevant logs (endpoint, authentication, PACS/RIS/EHR, proxy/DNS) to a write-once or read-only repository for incident evidence preservation.
• Decode the QR code offline to extract the URL or data payload without opening it in a live browser.
• Record who collected which artifacts, when, and from where to maintain a defensible chain-of-custody.

What to avoid

• Do not rescan the QR code on internet-connected devices; avoid “testing” the link in production.
• Do not alter original images or overlays prior to hashing and archiving.

Communication and Notification

Who to notify

• Security operations/CERT, privacy and compliance, legal, and imaging leadership per the IT security notification protocol.
• Application owners (PACS/RIS), networking, and endpoint teams to coordinate containment and analysis.
• Vendors or managed service providers if their platforms, scanners, or integrations may be involved.

How to communicate

• Use approved channels; share need-to-know facts only, avoiding PHI unless strictly necessary and protected.
• Provide concise situational updates: scope, suspected vectors, controls applied, and next milestones.
• If patient data exposure is suspected, engage privacy/legal to assess regulatory notification obligations.

Security Analysis

Phishing URL analysis (offline-first)

• Expand shortened links and examine full URLs for typosquatting, punycode, and unexpected query strings.
• Inspect TLS certificates, hosting metadata, and passive DNS to understand infrastructure relationships.
• Detonate content in a sandboxed lab if a QR code malicious payload is suspected (e.g., APK/IPA, macro-enabled files).

Endpoint and image path investigation

• Correlate browser history, download artifacts, and credential prompts on endpoints that scanned the code.
• Trace how the QR code entered the imaging workflow (device UI overlay, imported graphic, printed signage, or report template).
• Conduct malware forensic investigation on affected hosts: memory capture, IOC scanning, persistence checks, and lateral movement review.

Remediation Actions

Immediate fixes

• Remove or replace tainted images, overlays, or templates within PACS/RIS and workstation caches.
• Block domains/URLs identified during phishing URL analysis and purge related artifacts from endpoints.
• Rotate credentials exposed during the event; reset API keys and tokens tied to imaging systems.

Long-term hardening

• Strengthen security patch management for radiology workstations and connected systems in coordination with clinical engineering and vendors.
• Implement content integrity checks for overlays and templates; require approvals for any QR usage in imaging workflows.
• Restrict QR scanning on clinical workstations; prefer managed mobile devices with SAFE browsers and URL allowlists.
• Update training with clear guidance on QR code risks and reporting paths within the IT security notification protocol.

Post-Incident Review

Lessons learned and improvement

• Document root cause, timeline, control gaps, and which detections worked or failed.
• Refine runbooks for incident evidence preservation, phishing URL analysis, and malware forensic investigation.
• Add preventive controls: template signing, overlay provenance checks, and stricter content governance.
• Track metrics (time to detect, contain, and recover) and run a tabletop exercise to validate changes.

Conclusion

By identifying suspicious QR codes early, containing exposure quickly, preserving evidence rigorously, and closing gaps through security patch management and process upgrades, you protect fluoroscopy image integrity and reduce the risk of future QR-driven phishing incidents.

FAQs.

How to detect QR code phishing in fluoroscopy images?

Look for unexpected QR codes, style or placement mismatches, and low-quality overlays. Decode the QR offline and verify the full destination domain before any interaction. Check image metadata for post-acquisition edits and confirm that overlays align with approved templates.

What steps are included in immediate incident response?

Prioritize patient safety, isolate affected devices, block malicious domains, preserve images and logs, notify security per your IT security notification protocol, and document every action and timestamp. Stabilize operations using trusted workflows only.

How to preserve evidence in QR code phishing incidents?

Archive original images and compute hashes to maintain fluoroscopy image integrity, capture screenshots, export relevant logs to write-once storage, and decode QR data offline. Maintain a chain-of-custody record for all artifacts to support incident evidence preservation.

How to communicate QR code phishing threats effectively?

Use sanctioned channels, share clear facts (scope, indicators, actions taken), and avoid PHI unless protected. Notify SOC, privacy/legal, and imaging leadership promptly, align messaging with your IT security notification protocol, and provide timely updates as containment and analysis progress.