Safety Norms: Diagnostic and Interventional Radiology

1Purpose, Scope, and Safety Principles

This document defines the safety norms expected of everyone who takes part in diagnostic and interventional radiology in our department. It covers imaging examinations such as radiography, fluoroscopy, computed tomography, magnetic resonance imaging, and ultrasound, along with image-guided procedures such as biopsies, drainage, angiographic interventions, and vascular access. It applies to radiologists, radiographers, nurses, sedation providers, physicists, administrators, trainees, and contracted staff.

Four principles guide every rule. Patients come first. Radiation and contrast exposure must be justified and kept as low as reasonably achievable. Every procedure must be correctly identified and consented. Anyone who is unsure stops and escalates. A norm marked mandatory must be followed without exception unless an authorized person documents a justified deviation. A recommendation describes good practice that teams should adopt unless local conditions clearly make it unsuitable.

2Roles, Competence, and Accountability

The department head is accountable for resourcing, approved protocols, and a radiation protection program that meets local requirements. The radiation safety officer or medical physicist advises on dose, shielding, and equipment performance. The supervising radiologist owns diagnostic and interventional decisions, the scope of each procedure, and the final review of images. Technologists and nurses perform assigned tasks only after confirming their own competence.

Competence is documented, not assumed. Staff may perform a task only when they hold the qualifications or delegated authorization recorded under local rules. Sedation, contrast administration to higher-risk patients, and MRI operation each have separate authorization pathways. Anyone working outside their scope must stop and request a qualified colleague. Contractors and visiting staff must be briefed before entering controlled areas.

• Mandatory: no staff member performs a task without a current, recorded authorization.
• Mandatory: the supervising physician must be reachable and present for interventional procedures as local policy defines.
• Recommended: a named deputy is listed for each shift and each procedure room.

3Hazards and Risk Assessment

Realistic hazards include ionizing radiation to patients and staff, contrast media reactions, sedation-related respiratory depression, bleeding and vascular injury during needle and catheter work, infection from contaminated equipment or breaks in sterile technique, projectile injury from ferromagnetic objects near the magnet, cryogen and acoustic hazards, and misidentification of patients or treatment sides. Staff also face musculoskeletal strain from lead aprons and long procedures.

Each procedure type needs a documented risk assessment that rates likelihood and severity as low, medium, or high and names the control and its owner. Repeat the assessment when equipment, staffing, patient population, or procedure type changes. High-risk situations include MRI zone incursions, interventional procedures under sedation, contrast given to patients with known reactions, and procedures in pregnant patients where the clinical need is uncertain.

• Radiation: apply justification and dose optimization, and document dose information as local protocols require.
• MRI: treat every ferromagnetic object as a potential projectile and complete screening before zone entry.
• Contrast: identify prior reactions and renal risk per local protocol, and keep emergency medication immediately available.
• Sedation: monitor airway, oxygenation, and level of consciousness continuously by a trained person.

4Preventive Controls and Safe Procedure Practices

Begin every examination with two-identifier verification, such as full name and identification number, checked against the order and the wristband. Room number or bed location alone is never acceptable. Confirm the procedure, body part, laterality, and site marking before the patient is moved. Use a written pre-procedure checklist that covers allergy status, anticoagulant and antiplatelet use, pregnancy screening where relevant, renal risk per local protocol, implanted devices, and the patient's ability to lie still.

Informed consent must be obtained by a clinician authorized to do so under local law. That clinician explains the purpose, material risks, alternatives, and expected benefits, and answers questions. Patients may withdraw consent at any time. If a patient becomes confused or distressed, the team pauses rather than proceeds. Use interpreters or accessible formats when needed. Emergency consent rules differ by jurisdiction and must be verified locally.

• Mandatory: pause the procedure if any team member identifies an unresolved discrepancy in identity, side, or procedure.
• Mandatory: screen every person entering the MRI zone, including staff and visitors, before entry.
• Mandatory: complete a documented consent before any invasive step where local policy requires it.
• Recommended: use a written MRI safety questionnaire and a pre-entry briefing for accompanying adults.

5Radiation, Equipment, and Environmental Safeguards

Radiation safety relies on time, distance, and shielding, combined with dose optimization. Collimate to the area of clinical interest, use pulsed or reduced fluoroscopy settings where equipment and protocol allow, and keep exposure times as short as practical. Staff stay outside the primary beam or behind fixed shielding during exposure. Lead aprons, thyroid shields, and eyewear are used where the protocol requires, and lead equipment is inspected on the schedule set by the radiation protection program.

Check equipment before each list: emergency stop functions, table movement, monitoring displays, oxygen and suction supply, and crash equipment. Keep oxygen cylinders and other ferromagnetic items out of the magnet room. Maintain controlled access signage at MRI zone boundaries. Never use a unit that has an open fault until a qualified engineer has cleared it. Ventilation, room cleaning, and waste handling must follow local infection control policy.

• Mandatory: only MR safe or MR conditional items may enter the scanner room, verified against manufacturer labeling.
• Mandatory: staff must report lost or damaged dosimeters immediately.
• Mandatory: out-of-service equipment is tagged and removed from clinical use.
• Recommended: post a current dose-reduction summary at each fluoroscopy console.

6Infection Prevention and Hygiene

Interventional procedures that breach skin or vascular barriers require sterile technique managed by trained staff. Set up the sterile field immediately before use. Do not reuse single-use items unless the manufacturer labeling and local reprocessing policy allow it. The operator performs hand hygiene and wears sterile gloves, gown, mask, and cap as the procedure specifies. Skin antisepsis agents are chosen and applied according to local product labeling and allergy screening.

Between patients, clean tables, contrast injector surfaces, console keyboards, and touch points with approved disinfectants, and observe the contact times on the label. Reusable ultrasound probes and accessories are reprocessed according to manufacturer instructions. Sharps go into puncture-resistant containers at the point of use and are never recapped by hand. Staff with symptoms of a transmissible illness follow occupational health rules and tell the supervisor before patient contact.

• Mandatory: perform hand hygiene before and after every patient contact and after glove removal.
• Mandatory: discard single-use needles, catheters, and syringes after one patient.
• Mandatory: clean blood or body fluid spills immediately using the approved spill kit.
• Recommended: read a sterile-field checklist aloud during setup for complex interventions.

7Information, Privacy, and Security

Imaging records, reports, and images are protected health information. Access is limited to people with a treatment, payment, or operational need, consistent with local privacy law. Workstations lock when unattended, screens face away from waiting areas, and printed images or requisitions go into secure shredding bins. Do not photograph images or screens with personal devices, and do not discuss patients in corridors or public spaces.

Picture archiving systems, reporting platforms, and dose record systems are connected and must be secured. Access uses unique user accounts, multi-factor authentication where local policy requires it, and role-based permissions reviewed on a defined schedule. Remote image access and external transfers must use approved encrypted channels. Report suspected unauthorized access to the privacy officer and information security team at once.

• Mandatory: never share login credentials or work under another person's session.
• Mandatory: confirm the correct patient before sending images or reports to any external recipient.
• Mandatory: report lost media or devices containing patient images immediately.
• Recommended: provide patient information leaflets in the languages spoken in the local community.

8Incident, Emergency, and Escalation Procedures

Report every incident, near miss, and unsafe condition through the local incident system within the time frame set by policy. Near misses are treated as learning opportunities, not as blame. Examples include a wrong side identified before incision, contrast extravasation noticed during injection, unexpected sedation depth, and dose records that exceed the local reference level. Never alter records to hide an event.

Emergencies such as anaphylaxis, cardiac arrest, airway compromise, severe bleeding, or projectile injury in the MRI zone require immediate activation of the emergency response team and crash equipment. Stop the procedure, move the patient to a monitored area, and inform the supervising physician. Call local emergency services as the emergency plan directs. Escalate immediately when a team member is unsure, the patient deteriorates, or instructions conflict. Resuscitation medications and doses follow local protocols verified by a qualified clinician.

• Mandatory: a designated person leads MRI zone emergencies, including any approved quench procedure.
• Mandatory: treat contrast reactions according to the current local emergency protocol and document the response.
• Mandatory: disclose adverse events to the patient and family according to local disclosure policy.
• Recommended: run a simulated emergency drill in each procedure room on a scheduled basis.

9Records, Training, Monitoring, and Review

Documentation supports both safety and compliance. Each procedure record includes consent, safety screening, sedation notes where relevant, contrast details, dose information as required, equipment used, complications, and the supervising clinician's name. Retain records for the period set by local law. Training covers radiation protection, MRI safety, contrast management, sterile technique, sedation monitoring, emergency response, and privacy. Completion is recorded, and refresher training occurs at intervals set by the department and the regulator.

A governance group reviews safety performance regularly. The review examines incident trends, dose audits, contrast reactions, MRI zone breaches, infection control findings, and audit results. Actions are assigned to named owners with deadlines, and their effectiveness is checked later. This norms document and related protocols are reviewed on a defined cycle and whenever a serious event, regulatory change, or new equipment occurs. Verify current laws, standards, and manufacturer instructions with competent authorities or qualified professionals before adopting any rule.

• Mandatory: maintain current training and authorization records for every staff member.
• Mandatory: audit MRI screening and procedural time-out compliance at a defined frequency.
• Recommended: share lessons learned during brief safety huddles.

Implementation checklist

• Verify two identifiers plus procedure, side, and site before every examination.
• Confirm consent is documented and valid before any invasive step.
• Screen every person for MRI safety before zone entry, with no exceptions.
• Check contrast allergy history, renal risk, and pregnancy screening against local protocol.
• Justify each radiation exposure and use the lowest effective dose settings.
• Confirm sterile technique and hand hygiene before any needle or catheter use.
• Confirm sedation monitoring and emergency equipment are ready before starting.
• Lock workstations, protect images, and share only with authorized recipients.
• Report every incident and near miss within the policy time frame.
• Stop and escalate whenever you are unsure, outside your scope, or the patient deteriorates.
• Verify laws, standards, and manufacturer instructions with competent authorities or qualified professionals.