Standards › Standard 50 › Standard operating procedures (SOPs)
SOP · CTR-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 50.4
At a glance
- Every patient is pre-screened for allergy and renal function before contrast media is given (CTR-FRM-001).
- Informed consent is recorded before the study.
- Emergency treatment for a reaction is available immediately, and staff are trained in it.
- Each reaction is recorded and reviewed (PRO-FRM-006).
- Stop and get help straight away if: contrast media is given without a recorded allergy and renal function screen.
1. Purpose
To make sure contrast media is given safely, with screening, consent and an emergency response ready (50.4).
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
Contrast media can cause severe allergic reactions and kidney damage. A protocol that screens for allergy and kidney function before use reduces these risks.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Radiologist | Approves the contrast study and the screening | Clinical lead |
| Radiographer | Carries out the pre-screen and keeps the emergency kit ready | Radiologist |
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.
- Pre-screen for allergy and renal function, and record it (CTR-FRM-001).
Key point: Screened.
Step 2. Consent.
- Record informed consent before the contrast is given.
Key point: Consented.
Step 3. Respond.
- Keep the emergency kit ready and record any reaction (PRO-FRM-006).
Key point: Ready.
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 |
|---|---|---|---|---|
| Patients pre-screened before contrast | 100% | Monthly | Radiologist | Hold the study |
| Emergency kit checked each day | 100% | Daily | Radiographer | Escalate to the clinical lead |
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 |
|---|---|---|
| CTR-FRM-001 | Contrast media pre-screen and consent record | Record |
| PRO-FRM-006 | Adverse reaction record (existing, reused) | Record |
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)