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Radiation and General Safety (Revised 12-12-19)

Revision History

RS 1.0 - Radiation and General Safety

Standard: The facility must have policies and procedures in place to address all areas of safety for patients and personnel including limiting unnecessary exposure to radiation and insuring safety of the MRI environment. 

Elements of Compliance:

  • RS 1.1 The facility must have a designated Radiation Safety Officer (RSO) who is responsible for the radiation protection of the staff and the public if ionizing radiation is used. In most cases this person will be a medical physicist. If not a medical physicist or health physicist, the RSO should be a radiologist, nuclear medicine physician or radiation oncologist familiar with radiation safety requirements.

  • RS 1.2 The facility must have a Radiation Safety Committee that meets on a regular basis in compliance with state or federal regulations or at least semi-annually.

  • RS 1.3 Radiation and MRI hazard signs must be posted in appropriate, places including entrances to CT and MRI scan rooms, areas for radioactive materials, radioactive waste storage areas, and any hazardous material areas.

    • 1.3.1 For MRI, Zone III regions should be physically restricted from general public access by, for example, key locks, passkey locking systems, or any other reliable, physically restricting method that can differentiate between MR personnel and non-MR personnel (for definitions of the Zones in MRI see ACR Guidance Document for Safe MR Practices).

    • 1.3.2 For MRI Zone IV there must be a policy and procedure in the event of a loss of power to the site (for definitions of the Zones in MRI see ACR Guidance Document for Safe MR Practices).

  • RS 1.4 There must be a patient ID check including two identifiers before initiating the exam.

  • RS 1.5 All diagnostic imaging patients must be screened regarding previous or recent exams.

  • RS 1.6 Female diagnostic imaging patient of menstrual age (typically ages 12 through 50 years) must be questioned about pregnancy if there is a radiation risk. This would not be necessary for radiological examinations that render exposures to a pregnant uterus that are so low that pregnancy status need not alter the decision to proceed with a medically indicated examination, as long as the beam is properly collimated and the patient is positioned to avoid direct irradiation of the pelvis (e.g., mammography, chest radiography during the first and second trimesters, extremity radiography or extremity CT [with the possible exception of the hip] and diagnostic examination of the head or neck).

  • RS 1.7 All diagnostic imaging patients receiving contrast media must be screened for potential allergies or other adverse reactions before contrast is administered. 

  • RS 1.9 Standardized protocols must be in place for all exams. The medical physicist should participate in the development of the protocols in consultation with the radiologist.

  • RS 1.8 The following attributes must be included on all images:

  • Patient’s first and last name

  • Medical record number

  • Institution name

  • Date and time of examination

  • Date of birth or age of patient

  • Patient gender

  • Standardized view and laterality codes as appropriate

  • RS 1.10 The facilities must have protocols in place to optimize dose. Dose optimization entails controlling the amount of radiation received by the patient while ensuring the diagnostic integrity of the exam.

  • RS 1.11 Iso/Low-osmolality contrast media (LOCM) must be used. 

  • RS 1.12 A physician must be on-site at all times when contrast is administered.

  • RS 1.13 There must be adequate shielding for patients, personnel and facilities.

  • RS 1.14 A system to secure and dispose of radioactive materials including radionuclides and radioactive wastes must be in place. This system should also limit access to such materials.

  • RS 1.15 All sites must be in compliance with the current recommendations of the ACR Guidance Document for Safe MR Practice.

Standard: The facility must have policies and procedures in place to provide care in the event of an emergency such as a contrast reaction or cardiac arrest. Equipment appropriate to the site of care must be available.

Elements of Compliance:

  • RS 1.16 The facility must have a defibrillator on site.

  • RS 1.17 In hospitals serving adults, a crash cart with appropriate, unexpired drugs and equipment must be available. In non-hospital or pediatric hospitals, life support equipment appropriate to the patient population served must be available.

  • RS 1.18 If the facility does not provide emergency services, it must have written policies and procedures for appraisal of emergencies, initial treatment and appropriate referral.

  • RS 1.19 If the facility is off-campus to a hospital and does not provide emergency services; the department will coordinate and comply with written hospital policies for appraising and referring emergencies that occur off-campus. Off-campus facility staff should be aware of emergency policies and procedures and understand their roles and responsibilities.

Revision History for this Article



Description of Revision(s)



Article created; FAQs incorporated; No criteria changes

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