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Clinical Quality

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:

This policy applies to __________________________ (“Facility”).

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

1. The administration of oral/rectal Contrast Media without prior pharmacist


review has been determined to be a safe standard of practice provided that
medical staff-approved protocol is followed. See attached protocol
(Attachment A).

2. The administration of Systemic Contrast Media requires that:

a. A medical staff-approved protocol is followed.

b. Prior pharmacist review occurs with the exception of emergent


administration or when the administration of systemic Contrast
Media is under the direct supervision of a physician (the physician
or a licensed independent practitioner is available for timely
intervention in the event of an emergency).

c. See attached protocol (Attachment B).

3. Orders for Contrast Media must include the following information:

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:

b. Radiographic test to be performed

c. Administration instructions

d. See attached guidelines and procedures (Attachment D)

4. Appropriate consent must be obtained per hospital consent policy.


[Hospital to include P&P as reference.]

5. The patient will be advised regarding appropriate use of Contrast Media


and potential side effects that if they occur, must be communicated with the
patient’s physician.

6. In summary, the process for safe administration of Contrast Media begins


prior to administration and will include:

a. presence of risk factors identified and addressed

b. indication for use present or known

c. verification of correct agent, dosage and route present

d. verification of correct patient

B. Procurement

1. All Contrast Media will be obtained by the Pharmacy Department.

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.

a. An appropriate inventory level will be maintained at all times as


determined by the department that stocks the Contrast Media.

b. Only trained, designated licensed individuals (Radiology


Technologist, Physician or RN) may retrieve Contrast Media from a
limited set of secured radiographic medications.
Clinical Quality
No. CQ-3.006
Policies and Procedures
Page: 3 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. Storage

1. Contrast Media must be stored in accordance with manufacturer, state and


federal regulatory guidelines.

2. When applicable, if warmers are used, temperature logs shall be


maintained.

a. Any deviation from the recommended temperature shall be acted on


appropriately to correct the problem.

b. The pharmacy department must be notified of temperature


deviations and will determine if action regarding contrast media is
needed.

3. Radiographic material will be secured.

4. Pharmacy will verify correct storage conditions on a routine basis (e.g.


monthly floor reports).

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

Completion of medication reconciliation will be per hospital policy. [Hospital to


include P&P as reference.]

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

b. are taking a metformin-containing medication

c. have reduced renal function, renal disease or a solitary kidney

d. are pregnant or nursing

e. have had a previous history of allergy or reaction to contrast media

f. have had a clinically significant drug-contrast interaction

g. have significant respiratory or cardiovascular disease

h. are elderly

3. See attached screening tool(s) (Attachment C)

4. If hypersensitivity/allergy is noted to a radiographic contrast media, the


physician or licensed independent practitioner will be notified prior to
procedure for subsequent orders.

F. Administration

1. A Radiologist, a Registered Nurse or an authorized Radiology Technologist


may inject intravenous contrast agents for the purpose of the radiological
procedure.
Clinical Quality
No. CQ-3.006
Policies and Procedures
Page: 5 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:

a. administration must be within the individual’s scope of practice

b. competency must be established for management of types of IV


lines (e.g., peripheral vs. central line management)

2. Non-contrast medications used during the radiographic process may be


administered by those individuals authorized by licensure, scope of
practice, or organization policy to do so.

3. A physician shall be readily available to the patient before and during IV


contrast administration in the event an adverse contrast event were to
occur.

4. A pharmacist will be available if consultation is needed.

5. Prior to administration, the five rights of right patient, right medication


(contrast), right dose, right route, and right time shall be performed.

6. Prior to administration, appropriate labeling will occur unless contrast is


for immediate use. Labeling will include name of contrast, strength of
contrast, amount of contrast, and expiration date/time when expiration
occurs in less than 24 hours. The same labeling process is required when
auto injectors are used.

G. Monitoring

1. All Radiographic Contrast Material are monitored for adverse drug


reactions by the technologist/nurse/licensed independent practitioner.

2. If an adverse event/reaction was to occur, the physician/licensed


independent practitioner will be notified immediately. Treatment will be
rendered per physician order or emergent protocol.

3. Documentation of adverse events/reactions will be entered into the medical


record.

4. In addition, adverse events/reactions will be entered into eSRM, the


electronic safety and risk management incident reporting system.
Clinical Quality
No. CQ-3.006
Policies and Procedures
Page: 6 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:

5. In the event of an emergency situation, age-specific crash carts shall be


readily available for use.

6. Pharmacy shall ensure that a retrospective medication review occurs


periodically to determine that the screening system in place is being used
and is effective in identifying potential adverse events and to maximize
patient safety.

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:

- Prescription drug information for consumers and Professionals (www.drugs.com)

- The comprehensive resource for physicians, drug and illness information (www.rxmed.com)

- Contrast Medium Reactions, Recognition and Treatment (www.emedicine.com) Maddox TG,


Am Fam Physician 2002; 66: 1229-34, Adverse reactions to Contrast Material: Recognition,
Prevention and Treatment, 66 (7); 1229-1234; 2002) D.Kirchin MA, Contrast Agents for
Magnetic Resonance Imaging, Top Magn Reson Imaging, 14(5); 426-435; 2003.

- Rosovsky, MA, High-Dose Administration of Nonionic Contrast Media: a Retrospective


Review; Radiology, 200: 119-12; 1996.

- Medication Management and Contrast Media Discussion Guide, 2008. H. Cohen

- ACR Practice Guidelines for Use of Intravascular Contrast Media (2006)


http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/dx/iv_contrast.aspx

- 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
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Protocols.doc and Procedure.doc