Standards › Standard 50 › Standard operating procedures (SOPs)
SOP · MRI-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 50.5
At a glance
- Every patient and accompanying person is screened for MRI contraindications before entering the magnet room (MRI-FRM-001).
- The magnet room is divided into zones, with physical control at the entry to the magnetic field.
- Unscreened people are not allowed past the zone entry.
- Implants and devices are checked against the MRI-conditional list before the study.
- Stop and get help straight away if: an unscreened person is allowed into the magnetic field.
1. Purpose
To make sure no one enters the magnetic field without screening, and that the zones are physically controlled (50.5).
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
A metal implant or device can move or heat up in an MRI scanner and injure the patient or the person accompanying them. Screening everyone before they enter the scanner prevents that.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| MRI safety officer | Owns the zones and the screening standard | Radiologist |
| Radiographer | Screens each person and controls the zone entry | MRI safety officer |
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. Screen.
- Screen each person for MRI contraindications before entry (MRI-FRM-001).
Key point: Screened.
Step 2. Control.
- Keep the zone entry physically controlled, and turn away anyone not screened.
Key point: Controlled.
Step 3. Check implants.
- Check any implant or device against the MRI-conditional list.
Key point: Checked.
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 |
|---|---|---|---|---|
| Persons screened before entry | 100% | Each study | Radiographer | Stop the study and re-screen |
| Zone entry controlled on every session | 100% | Daily | MRI safety officer | Escalate to the radiologist |
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 |
|---|---|---|
| MRI-FRM-001 | MRI safety screening record | Record |
| IMG-SOP-001 | Imaging equipment quality assurance (existing, reused) | SOP |
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)