Medical Physicist or Qualified Expert Guidance Document



IAC MRI Safety Checklist / Guidance Document

|1. Review and Oversight |

| |Are MRI safety policies and procedures well documented |Standards Reference - (4A) |

| |and reviewed annually by the QI Committee or Medical | |

| |Director? |Yes No |

|2. Examination Room |

|a. |Is access to the examination room well defined, | Yes No |

| |controlled and supervised by a technical staff member? | |

|b. |Is the entrance and door to the examination room clearly | Yes No |

| |marked as hazardous, with appropriate warning signs | |

| |displayed? | |

| | | |

| |Are the screening areas/public passageways placed beyond | |

| |the magnetic fringe field (5.0 Gauss)? |Yes No |

|c. |Is there a method for continuous visual, verbal and/or |Standards Reference - (4A) |

| |physiological monitoring of the patient during the | |

| |examination? |Yes No |

|d. |Is hearing protection available and offered to every |Standards Reference - (4A) |

| |patient? | |

| | |Yes No |

|3. Screening |

|a. |Is there a mechanism in place to identify those |Standards Reference- (4A) |

| |patients/staff members/visitors at high risk for untoward| |

| |effects or complications from entering the MRI |Yes No |

| |environment? | |

|b. |Is there a mechanism in place that | Yes No |

| |assures that patients who could be pregnant are | |

| |identified, along with an explanation of the proper steps| |

| |to be taken if a patient may be or is pregnant? | |

|4. Training |

|a. |Is there a policy in place to educate, train and screen |Standards Reference - (4A) |

| |all MRI facility staff members and personnel that may be | |

| |required to enter the MRI environment? |Yes No |

| b. |Was a minimum of one hour of MRI safety instruction |Standards Reference - (1A) |

| |completed for the medical and technical staff? | |

| | |Yes No |

|5. Emergency Preparedness |

|a. |Is there a written policy in place in the event of a MRI |Standards Reference - (4A)/comments |

| |procedure-related emergency for patient management that | |

| |includes rapid recognition, response and removal of the |Yes No |

| |patient from the magnet room to administer emergency | |

| |care? | |

|6. Equipment Maintenance Assessment |

|a. |Was there an acceptance test performed after the MRI |Standards Reference - (1B) |

| |system installation or following a major upgrade by the | |

| |manufacturers representative, service engineer or the |Yes No |

| |site-appointed medical physicist? | |

| | | |

| |Does the report include the QC tests performed, the | |

| |results as compared to manufacturer’s or industry |Yes No |

| |guidelines, | |

| |recommendations to the facility (if any) and was the | |

| |report signed and dated by the person performing the | |

| |tests? | |

| b. |Is a Preventative Maintenance (PM) service performed at |Standards Reference - (1B) |

| |least every 12 months? |Yes No |

| | | |

| |Was the report of the PM, quality control tests and | |

| |service records maintained at the MRI facility? |Yes No |

| | | |

| |Was the report signed and dated by the person(s) | |

| |performing the tests? |Yes No |

| |Are the routine quality control (QC) tests being |Standards Reference - (1B) |

|c. |performed by the technical staff operator in accordance |Yes No |

| |with the IAC MRI Standards and the manufacturer’s | |

| |recommendations? | |

| | | |

| |Did the QI committee review the QC testing and a facility| |

| |safety review at a minimum annually? |Yes No |

|7. Safety Policies |

|a. |Is there a procedure in place for the identification of a|Standards Reference - (4A) |

| |patient or individual (i.e., visitor, staff member) who |Yes No |

| |suffers an incident or complication from the MRI | |

| |examination or exposure to the MRI environment? | |

| | | |

| |Is there documentation of this incident? | |

| | |Yes No |

| b. |Is there a procedure in place to address possible |Standards Reference - (4A) |

| |contraindications that include Nephrogenic Systemic | |

| |Fibrosis (NSF) and contrast material sensitivity, if |Yes No |

| |used, and allergies to medications? | |

| c. |Is the administration of contrast agents, medication |Standards Reference - (4A)/comments |

| |and/or sedation performed by licensed or qualified | |

| |trained personnel, under the direct supervision of a |Yes No |

| |licensed physician or in compliance with federal, state | |

| |or local laws? | |

| d. |If cardiovascular procedures are performed, are there MRI|Standards Reference- (4A) |

| |safety policies that include a detailed description of | |

| |the graded protocols and/or infusion protocols described?|Yes No |

| | | |

| |These protocols must include the timing of assessing | |

| |symptoms, heart rate, blood pressure and | |

| |electrocardiographic tracings; exercise testing end | |

| |points; pharmaceutical injection criteria and post stress| |

| |monitoring. | |

|8. Finalization |

| |Do the QI meeting minutes reflect the review of clinical | Yes No |

| |image quality, QC testing and MRI safety? | |

|9. Recommendations |

| |Are there recommendations, actions needed, or issues to | Yes No |

| |be addressed? | |

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