Professional Documents
Culture Documents
No. CQ-3.006
Policies and Procedures
Page: 1 of 7
Origination Date: 10-16-09
[INSERT
HOSPITAL Effective Date: 10-16-09
LOGO] RADIOGRAPHIC CONTRAST
MEDIA Retires Policy Dated:
Previous Versions Dated:
Hospital Governing Board
Approval Date:
I. SCOPE:
II. PURPOSE:
The purpose of this policy is to address the proper review, storage and safe administration of
Radiographic Contrast Media (“Contrast Media”).
III. POLICY:
Contrast Media are considered medications and must be provided to patients in a safe manner and
in accordance with all pertinent state and federal regulations and applicable accreditation
standards.
IV. PROCEDURE:
A. Physician Orders
a. Contrast to be used
Clinical Quality
No. CQ-3.006
Policies and Procedures
Page: 2 of 7
Origination Date: 10-16-09
[INSERT
HOSPITAL Effective Date: 10-16-09
LOGO] RADIOGRAPHIC CONTRAST
MEDIA Retires Policy Dated:
Previous Versions Dated:
Hospital Governing Board
Approval Date:
c. Administration instructions
B. Procurement
2. Once Contrast Media are received and checked in by Pharmacy, they will
be distributed as floor stock to those areas identified as requiring a
radiographic contrast agent inventory (PAR) level.
C. Storage
5. Retrieval of the Contrast Media from the secured storage area shall be as
needed per patient need.
6. In the event that there is a problem with the product, or a product is being
recalled, the pharmacy will be notified and will initiate the recall process to
ensure removal from inventory. Documentation of recall actions will be
maintained in the pharmacy department.
7. Only formulary Contrast Media are to be routinely stocked and stored. All
contrast media shall be evaluated and approved through the formulary
process as determined by the Pharmacy & Therapeutics (P&T) Committee.
D. Medication Reconciliation
E. Screening
Clinical Quality
No. CQ-3.006
Policies and Procedures
Page: 4 of 7
Origination Date: 10-16-09
[INSERT
HOSPITAL Effective Date: 10-16-09
LOGO] RADIOGRAPHIC CONTRAST
MEDIA Retires Policy Dated:
Previous Versions Dated:
Hospital Governing Board
Approval Date:
1. When appropriate, a recent (within the last 30 days) serum creatinine (SCr)
shall be obtained and reviewed for potential contraindications in use of
contrast. In the event a recent SCr is not available, an order to obtain an
SCr prior to the scheduled procedure will be obtained.
2. In the event the screening process determines that the patient is at-risk for
an adverse event due to administration of radiographic contrast media, the
technologist/nurse is required to contact the physician or LIP for next step
orders. At-risk patients can include, but are not limited to, those patients
that:
a. are diabetic
h. are elderly
F. Administration
G. Monitoring
H. Enforcement
All employees whose responsibilities are affected by this policy are expected to be
familiar with the basic procedures and responsibilities created by this policy. Failure
to comply with this policy will be subject to appropriate disciplinary action
pursuant to all applicable policies and procedures, up to and including termination.
Such disciplinary action may also include modification of compensation, including
any merit or discretionary compensation awards.
V. REFERENCES:
- The comprehensive resource for physicians, drug and illness information (www.rxmed.com)
- Overview of Contrast Media: Critical Knowledge for Health-Systems Pharmacists – 43rd ASHP
Midyear Clinical Meeting and Exhibition.
Clinical Quality
No. CQ-3.006
Policies and Procedures
Page: 7 of 7
Origination Date: 10-16-09
[INSERT
HOSPITAL Effective Date: 10-16-09
LOGO] RADIOGRAPHIC CONTRAST
MEDIA Retires Policy Dated:
Previous Versions Dated:
Hospital Governing Board
Approval Date:
VI. ATTACHMENTS:
- Attachment A: Oral/Rectal Radiographic Contrast Media Protocol [Hospital will use its
established protocol]
- Attachment B: Systemic Contrast Media Protocol [Hospital will use its established protocol]
- Attachment C: Screening Tools [Hospital will use its established screening tools]
- Attachment D: Radiology Guidelines and Procedure [Hospital will use its established
formulary and guidelines or can create using examples included below.]
Radiology Protocols
Radiology Procedure Radiology Guidelines Doc8.doc Doc9.doc
Showing Do...
Protocols.doc and Procedure.doc