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How? [CONTINUED FROM PAGE 1]

Recommended Components for Policies and Procedures:

1) The policy should be laboratory-specific.

2) The policy should appear on the laboratory, clinic, office, hospital or medical center's letterhead.

3) The policies should be numbered (e.g.: MRI policy #5).

4) The policy should have a title (e.g.: Acute Medical Emergency Policy).

5) The policy should be stated at the beginning of the document, inclusive of a statement outlining the goal and purpose (e.g.: It is the policy of Potomac Valley Imaging Center to inform and educate all personnel on the proper procedures to be taken in the event of a medical emergency in the magnet room.)

6) The procedure document details the step-by-step process that outlines how the goal stated in the policy will be achieved. For example:

In the event of an adverse event or emergency in the magnet room:
- stop the scan
- assess patient's condition
- call for help (include number)
- remove patient from the bore or from the scanner room
- start CPR, if needed
- assist emergency personnel, as requested

7) The procedure document should include the effective date, revised date, and review date.

8) The procedure document should include the approval signature(s) from member(s) of the QA Committee.

9) The procedure document should be detailed and inclusive of precise functional instructions. The exact action to be taken and when should be specified. In contrast, it is best not to include what not to do as this will only add confusion.

The following policies and procedures are required within The ICAMRL Standards and must be submitted as part of a completed accreditation application, if applicable:

ORGANIZATION: PART I

Section 4

• resolution of discrepancies between preliminary and final interpretations (if preliminary reports are generated)

Section 5

• patient and personnel safety
• protection of patients and staff from infectious disease and blood borne pathogens
• equipment cleaning
• acute medical emergency
• patient confidentiality
• environmental safety issues related to the MR system (i.e.: ferromagnetic objects, protective ear devices, radio frequency burns)
• education, training, and screening

Section 7

• Quality Assurance program and oversight

Testing: Part II, Section 4

• Technical and Interpretive QA

By developing, implementing and maintaining laboratory-specific policies and procedures in accordance with the guidance provided, magnetic resonance imaging facilities will be in a position to provide improved patient care, as defined by The ICAMRL Standards.

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