Standards › Standard 50 › Standard operating procedures (SOPs)
SOP · IMG-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 50.2
At a glance
- All imaging equipment has a quality assurance schedule, set by the manufacturer and the regulator.
- Testing and calibration are done by qualified personnel and recorded (IMG-REG-002).
- Equipment that fails a test is taken out of use until it is repaired and passes again.
- Each test is recorded with the result and the next due date.
- Stop and get help straight away if: imaging equipment is used after it has failed a quality assurance test.
1. Purpose
To make sure imaging equipment is tested and calibrated on schedule, and out of use when it fails (50.2).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
An imaging machine out of calibration gives wrong pictures, and wrong pictures lead to wrong decisions. Quality testing and calibration on schedule keep the images reliable.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Medical physicist | Sets the schedule and carries out or checks the tests | Radiologist |
| Radiographer | Takes equipment out of use on a failed test | Medical physicist |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Schedule.
- Set the quality assurance schedule for each piece of equipment.
Key point: Scheduled.
Step 2. Test.
- Test and calibrate on schedule, and record the result (IMG-REG-002).
Key point: Tested.
Step 3. Act on failure.
- Take failed equipment out of use until it is repaired and passes.
Key point: Acted.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Tests done on schedule | 100% | Monthly | Medical physicist | Escalate to the radiologist |
| Failed equipment out of use on the day | 100% | Each failure | Radiographer | Stop the equipment |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| IMG-REG-002 | Imaging equipment quality assurance register | Register |
| DEN-REG-003 | Radiation equipment and dose audit register (dental, existing, reused) | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)