1. Purpose
This policy sets out how the Service screens patients, staff, visitors and contractors before access to MRI controlled areas, manages MRI Zone 1 to Zone 4 access and responds to MRI safety incidents.
It covers ferromagnetic risk, implant risk, radiofrequency burn risk, quench response and local escalation.
2. Sources to verify before adoption
- MHRA Safety Guidelines for Magnetic Resonance Imaging Equipment in Clinical Use: https://www.gov.uk/government/publications/safety-guidelines-for-magnetic-resonance-imaging-equipment-in-clinical-use
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 12: https://www.legislation.gov.uk/uksi/2014/2936/regulation/12
- MHRA Yellow Card reporting site: https://yellowcard.mhra.gov.uk/
- Society of Radiographers professional guidance and publications: https://www.sor.org/
- HCPC standards of proficiency for radiographers: https://www.hcpc-uk.org/standards/standards-of-proficiency/radiographers/
- Current MRI scanner manufacturer safety manual and local service contract documents.
3. Scope
This policy applies to:
- MRI referral acceptance
- patient MRI safety screening
- implant and device verification
- pregnancy screening where relevant
- claustrophobia and anxiety support
- MRI Zone 1, Zone 2, Zone 3 and Zone 4 controls
- staff, contractor, cleaner, engineer, visitor and family access to MRI areas
- ferromagnetic incident response
- thermal or radiofrequency burn response
- planned and unplanned quench response
- MRI equipment faults and manufacturer escalation
The policy applies to fixed MRI, mobile MRI hosted at the Imaging Centre and any subcontracted MRI session controlled by the Service.
4. MRI screening and access process
The Service does not allow any person or object into Zone 4 until MRI safety screening is complete and recorded.
4.1 Pre-appointment screening
Booking staff issue or complete a screening form before the appointment where possible.
The screening form covers:
- cardiac pacemaker or implantable defibrillator
- neurostimulator, cochlear implant or programmable shunt
- aneurysm clip, stent, filter or vascular device
- metallic foreign body, including eye injury history
- prior surgery involving implants or metalwork
- infusion pump, glucose monitor or wearable device
- pregnancy or possible pregnancy
- renal-risk or contrast question where contrast MRI is booked
- claustrophobia, anxiety or need for support
- mobility, communication or pain needs
If an answer is uncertain, booking staff escalate to the MRI Safety Officer or Radiographer before confirming the appointment.
4.2 On-arrival screening
Radiography staff repeat the safety screening on arrival. Staff do not rely solely on the booking form.
The on-arrival check includes:
- patient identity
- procedure requested
- screening form completion
- implant evidence or device card where relevant
- removal of metal and electronic items
- clothing check
- pregnancy question where relevant
- consent to continue
- support need and communication method
The Radiographer stops the scan if the patient cannot answer safely and no lawful alternative confirmation route is available.
4.3 Zone access control
The Service defines local controls for each MRI zone.
- Zone 1: public access area before MRI screening.
- Zone 2: supervised interface where initial screening and preparation take place.
- Zone 3: controlled area with restricted access for screened staff and patients.
- Zone 4: scanner room, accessible only when authorised by MRI-trained staff.
The Service displays local signage, controls doors and records exceptions. Contractors and visitors do not enter Zone 3 or Zone 4 unless screened and escorted under the local procedure.
4.4 Implant and device verification
Staff verify implants and devices before scanning.
Verification may include:
- manufacturer implant card
- medical record
- referrer confirmation
- device database checked under local procedure
- radiologist or MRI Safety Officer decision
- manufacturer advice where needed
If compatibility cannot be confirmed, the Service does not scan until a competent role holder has completed and recorded the risk decision.
4.5 Pregnancy and claustrophobia
Staff follow the local pregnancy-screening procedure for patients of childbearing potential.
For claustrophobia or anxiety, Staff consider:
- preparation call before attendance
- patient visit to the scanner area before the appointment
- agreed communication signal
- mirror, music or support person where safe
- rescheduling with referrer advice where sedation or medication may be needed
The Service records any decision to stop or abandon the scan.
4.6 In-scan monitoring
The Radiographer keeps contact with the patient during the scan.
Monitoring covers:
- call-bell or agreed signal
- pain, heating or burning sensation
- anxiety or panic
- movement that may affect safety or image quality
- equipment warning
- staff line of sight or communication route
Staff stop the scan if the patient reports burning, pain, distress or a safety concern.
5. MRI incident response
The Service records MRI incidents in the incident register and reviews whether external reporting is required.
5.1 Ferromagnetic or projectile incident
If a ferromagnetic item enters Zone 4 or moves towards the magnet, Staff:
- stop patient movement into the room
- keep people away from the object
- call the MRI Safety Officer or senior Radiographer
- assess patient and staff harm
- do not attempt unsafe retrieval
- contact the manufacturer or engineer where required
- record the incident
- review screening, signage and access control
The Service considers MHRA Yellow Card reporting where the incident involves equipment, device or safety-system failure.
5.2 Thermal or radiofrequency burn
If a patient reports heating or burning, Staff:
- stop the scan
- assess the patient
- arrange medical review where needed
- preserve scan protocol and coil details
- record patient position, padding and contact points
- record clothing, monitoring leads and devices involved
- escalate to the MRI Safety Officer and manufacturer where needed
- assess duty of candour where harm occurred
5.3 Quench event
The Service has a written quench response procedure.
The procedure covers:
- evacuation route
- oxygen-depletion risk
- door opening procedure
- emergency service call point
- manufacturer contact
- patient evacuation
- room access restriction
- post-event engineering sign-off
- service interruption communication
Staff do not re-enter or restart scanning until the manufacturer, engineer or competent local role confirms it is safe.
6. Training and drill requirements
Staff who work in MRI areas complete MRI safety training before unsupervised access.
Training covers:
- MRI zone controls
- patient screening
- implant escalation
- ferromagnetic risk
- burn prevention
- emergency stop process
- quench response
- contractor and visitor screening
- incident reporting
The MRI Safety Officer keeps the training matrix current and restricts access where training has expired.
7. Responsibilities
- Registered Manager: owns this policy, ensures MRI safety governance is reviewed and signs off annual review.
- MRI Safety Officer: owns MRI screening, zone controls, incident escalation, quench drills and staff training oversight.
- Radiographer: completes screening, controls Zone 4 access, monitors the patient and stops unsafe scans.
- Radiologist: advises on clinical risk, implant uncertainty, contrast-linked MRI decisions and clinical alternatives.
- Operations Manager: ensures booking, signage, contractors, maintenance visits and room access follow the local process.
- All staff: do not bring unscreened people or objects into controlled MRI areas.
8. Recording requirements
The Service keeps the following records:
- MRI safety policy
- MRI zone map
- screening forms
- implant or device verification record
- pregnancy-screening record where applicable
- scan stop or abandoned scan record
- visitor and contractor screening record
- quench drill record
- MRI incident record
- manufacturer or engineer advice
- Yellow Card decision where applicable
- duty of candour decision where applicable
- training matrix
Records are kept in the Service governance records and linked to the patient record where relevant.
9. Audit cadence
The Service uses the following Verivius default audit rhythm unless current MHRA, SCoR, manufacturer, CQC or local source material requires a different rhythm:
- Per scan: Radiography staff record completed MRI screening before Zone 4 access.
- Monthly: the MRI Safety Officer audits a sample of screening forms and access exceptions.
- Quarterly: the Registered Manager reviews MRI incidents, abandoned scans and contractor access.
- Annually: the Service completes a quench drill and reviews MRI zone controls.
- After any MRI safety incident: the Service reviews screening, signage, training, equipment and improvement actions.
Audit findings are recorded as improvement actions with an owner and review date.
10. Version control and review date
The Service keeps a controlled copy of this policy. The footer or document-control table records:
- policy owner
- version number
- date approved
- next review date
- changes made since the last version
- source material checked during the review
11. Related records
- MRI screening form
- MRI zone map
- Visitor and contractor screening log
- Training matrix
- Incident register
- Equipment service record
- Quench drill record
- Duty of candour policy
- Improvement action register
Review cadence: annual or on regulatory change, whichever sooner. Owner: Registered Manager.