We’ve raised safety issues related to MRI scanning in multiple previous articles. In our Patient Safety Tips of the Week February 19, 2008 “Preventing accidents and injuries in the MRI suite” and the American College of Radiology's updated guidance document for safe MR practices (Kanal et al 2007). We won’t repeat here the numerous recommendations in those articles. But we did emphasize that your quality improvement program needs not only to review all incidents and near misses related to MR imaging but that you should also perform some sort of audits of adherence to the screening and other safety procedures. Results need to be incorporated into feedback to staff and lessons learned need to be readily shared. We also suggested that safety in the MRI suite is a great topic for a topic for FMEA (Failure Mode and Effects Analysis). It is also a good practice to do drills or simulations of emergencies in the MRI suite. You could simulate a cardiac or respiratory arrest or a fire in the MR unit. In any event, you should have periodic drills for some of the potential disasters, such as fires. We also noted an MRI suite safety calculator available online is a good place to start when you are looking at your MR safety program.we discussed Joint Commission’s Sentinel Event Alert “
The VA health system has just published the results of an MRI safety audit they performed on 50 MRI suites in 43 of their facilities. They initiated this system wide audit in response to an event, described in detail later, that had taken place in one of their MRI units. All their units endorse the ACR guidelines and have policies generally consistent with those guidelines.
Overall, the units performed quite well but it is important to share with others those opportunities for improvement that they identified. The VA system is at the head of the pack when it comes to patient safety systems so you can bet that any issues they identified are likely to be present at most organizations.
There were four main areas identified for improvement. First had to do with training of personnel. This, of course, applies not only to the staff working directly in the MRI suite but also to any personnel that may need to enter the MRI suite. They require initial MRI safety training and then annual refresher training for all staff that may need to enter the MRI suite (eg. technologists, nurses, emergency response teams, etc.). They found evidence of training during orientation in 72% of such employees and evidence of annual training in 89% for those working for more than 2 years. One of the recommendations emanating from the audit is to develop standardized training modules (to ensure consistency of content) and to provide the training through an automated system (eg. online modules) to allow for monitoring compliance.
To those recommendations we add some of our own. Some hospitals, particularly those having behavioral health units, have separate emergency response teams for “unruly patient” events. You need to make sure that all the personnel you have identified to serve on those teams are identified as being in need of the MRI safety training and updates. Also, since the claustrophobia often seen in the MRI suite may lead to behavioral health patients suddenly decompensating, it is imperative that your MRI staff have appropriate training in the techniques used in behavioral health to de-escalate behaviors in such patients. And your periodic drills should therefore include not just ones for “medical” emergencies but also for behavioral health emergencies occurring in the MRI suite. And don’t forget that there are multiple other personnel (eg. maintenance, housekeeping, your local firemen and policemen) that may need to enter the MRI suite at some time. Consider, in particular, including the fire and police personnel in some of your simulations and drills.
The second VA audit recommendation had to do with screening patients prior to MRI. They correctly point out that most serious incidents occurring in MRI suites have been due to deficiencies in screening methods or lack of strictly controlled access to MRI units. Each unit needs to utilize a screening form or checklist that includes all the devices, equipment, etc. that is not allowed in the magnet room. The MRI technologist who screens the patients is required to sign the screening form, which is then to be kept on record. Keeping that form as part of the medical record is valuable in the event that patient has to return for an emergent MRI at some time. The audit found the screening forms in 89% of cases, with technologist signatures in 82% and patient signatures in 78%. Also, when a potential contraindication to MRI is identified, documentation of the followup needs to be documented on the screening form. They found evidence of that in only 57% of cases.
The screening procedure is described in the ACR Guidance in detail. It talks about questions to be asked during screening, physical findings, screening techniques and procedures, who needs x-ray screening for potential ferromagnetic clips, implants, etc. It also discusses issues related to special circumstances such as pregnancy, patients needing sedation, patients needing accompaniment and other issues. No one could possibly confine to memory everything that must be considered during the MR screening process. Ferromagnetic materials may be present in things like tattoos, makeup, drug patches, unretrieved device fragments, and other places you’d never suspect. Hence, good use of checklists is a must. And the list keeps changing. For example, the list of drug patches containing metal keeps changing (Hong 2010).
The third audit recommendation had to do with informed consent. VA policies require informed consent for us of contrast media in high-risk patients. They only identified 14 patients in this category but appropriate informed consent was completed in only 50% of those. It is important to have pre-screening in place to identify such high-risk patients and avoid contrast if possible. But where the potential benefits of a contrast examination outweigh the potential risks, appropriate informed consent should be obtained.
The fourth recommendation had to do with the physical environment in the MRI suite and emergency preparedness. Generally, all their units had appropriate signage to help prevent unauthorized or accidental access to MRI areas but actual physical barriers were present in only 80% of sites. Facilities are required to have direct visual observation of access corridors from their working positions and to be able to communicate two-way with patients who are in the scanner. Though it was a problem with the latter that led to the audit (see below), the audit showed high degrees of compliance with these requirements. However, they identified issues with the emergency call systems. Documentation of preventive maintenance of the call systems was found in only 82% and only 74% regularly tested their call systems. Use of drills was also suboptimal. Fire drills were conducted in only 64% and drills for medical or mental health emergencies were conducted in only 44%.
Interestingly, the VA audit of MRI safety was initiated after a 2008 incident (Report No. 08-01380-154) in which a patient crawled out of an MRI scanner after his calls for help went unheeded because the panic button was inoperable and no maintenance checks had been done on the intercom system or the panic button. That, of course, is reminiscent of one of the earliest patient safety events that was memorialized in Steven Casey’s “Set Phasers on Stun” (Casey 1993). The 2008 VA incident also illustrates another serious error we have frequently commented upon in the past – the volume on the intercom system was frequently turned down by staff because of excessive noise (see our Patient Safety Tips of the Week for March 5, 2007 “Disabled Alarms”, and February 23, 2010 “Alarm Issues in the News Again”).
Every facility that performs MRI imaging needs to have an audit process in place to ensure compliance with safety measures. That audit should also include consideration of other vulnerabilities in the radiology suite in general, such as medication errors, anesthesia/sedation, infection control etc.
Prior columns on MRI safety:
Joint Commission. Sentinel Event Alert. Preventing accidents and injuries in the MRI suite. Issue 38. February 14, 2008
Kanal E et al. ACR Guidance Document for Safe MR Practices: 2007. AJR 2007; 188: 1-27 http://www.acr.org/SecondaryMainMenuCategories/quality_safety/MRSafety/safe_mr07.aspx
Department of Veterans Affairs Office of Inspector General. Evaluation of Magnetic Resonance Imaging Safety in Veterans Health Administration Facilities. Report No. 09-01038-77. January 26, 2011
Hong I, Gabay M, Lodolce A. Safety concerns involving transdermal patches magnetic resonance imaging [MRI]. Hosp Pharm 2010; 45(10): 771–778
Report No. 08-01380-154. Department of Veterans Affairs Office of Inspector General. Healthcare Inspection Alleged Patient Neglect During a Magnetic Resonance Imaging Exam Michael E. DeBakey VA Medical Center Houston, TX. Report No. 08-01380-154. June 27, 2008
Casey S. Set Phasers on Stun and Other True Tales of Design, Technology, and Human Error. Santa Barbara California: Aegean Publishing Company, 1998 (first published in 1993)