Standards › Standard 57 › Standard operating procedures (SOPs)
SOP · RTH-SOP-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 57.3
At a glance
- Each treatment machine is checked on the documented quality assurance schedule (RTH-REG-001).
- Output and safety interlocks are checked against the tolerance.
- A machine that fails a check is taken out of clinical use until it is repaired and re-tested.
- Stop and get help straight away if: a treatment machine is used clinically after a failed check or after its scheduled check is overdue.
1. Purpose
To make sure treatment machines deliver the planned dose safely (57.3).
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
To make sure treatment machines deliver the planned dose safely (57.3).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Medical physicist | Runs the quality assurance schedule and records the results | Clinical lead |
| Radiation oncologist | Decides on clinical use after a failed check | Clinical lead |
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. Check.
- Run the scheduled output and safety checks and record them (RTH-REG-001).
Key point: Checked.
Step 2. Decide.
- Compare each result with the tolerance. Take any failed machine out of use.
Key point: Decided.
Step 3. Re-test.
- Re-test the machine after repair before it returns to clinical use.
Key point: Re-tested.
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 |
|---|---|---|---|---|
| Scheduled machine checks completed on time | 100% | Monthly | Clinical lead | Escalate to the hospital director |
| Failed checks with the machine taken out of use | 100% | Monthly | Clinical lead | Stop clinical use at once |
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 |
|---|---|---|
| RTH-REG-001 | Machine quality assurance register | Register |
| IMG-SOP-001 | Imaging equipment quality assurance and calibration (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)