MRI safety is the focus of new Sentinel Event Alert
The Joint Commission has issued a Sentinel Event Alert on preventing accidents and injuries in the magnetic resonance imaging (MRI) suite.(To access the complete alert, go to www.jointcommission.org. Under "Sentinel Event," click on "Sentinel Event Alert," "Issue 38 - February 14, 2008: Preventing accidents and injuries in the MRI suite.")
A total of five MRI-related cases have been reported to The Joint Commission's Sentinel Event database, resulting in four deaths, including one case caused by a projectile and three cardiac events. The other case involved a misread MRI scan that resulted in delayed treatment.
An analysis of the FDA's Manufacturer and User Facility Device Experience Database revealed 389 reports of MRI-related events over a 10-year period, including nine deaths. Three were related to pacemaker failure, two to insulin pump failure, and the remaining four events related to implant disturbance, a projectile, and asphyxiation from a cryogenic mishap during installation of an MRI imaging system. More than 70% of the 389 reports were burns and 10% were projectile-related.
"We are already following The Joint Commission's recommendations," reports Deanne Roe, director of radiology at St. Joseph's Hospital and Medical Center in Phoenix. "Our area has restricted access, and all patients are screened a minimum of two times prior to entering the magnetic field."
The hospital's MRI employees are trained and updated on an ongoing basis as new implantable and environmental devices become available on the market.
Safety training is also offered to staff from other departments such as facilities, environmental services, and operating room staff. "We have MRI-compatible physiologic monitors in every scanner, as well as compatible anesthesia and infusion equipment," says Roe. "Magnetic field safety is a primary focus for MRI staff."
At Medical College of Georgia in Augusta, clinical quality is the top strategic priority established by the hospital's board. "MRI safety is regularly tracked by our patient care quality and safety program as one of the ways in which we address this top organizational priority," says David A. Snyder, MD, vice president of patient care quality and safety.
Any problems identified with MRI safety are tracked through Patient Safety Net, an incident reporting system that helps identify opportunities for improvement internally. The system also benchmarks the hospital's performance against that of other hospitals and medical centers in the University HealthSystem Consortium, a benchmarking organization in Chicago that serves more than 200 hospitals and medical centers nationally.
"MRI safety incidents at Medical College of Georgia have been rare, and none to my knowledge have resulted in a significant injury to a patient or staff member," says Snyder.
An MRI safety training module is available to staff as a web-based tool, so training can be completed at convenient times. "This also allows us to track that training. Our goal is to have 100% of our staff trained annually on this important topic," says Snyder.
"We are also very aware of the recent Joint Commission safety alert concerning MRI safety," adds Snyder. "We were already compliant with many of the best practices identified in the alert. And we now have specific actions in progress that, when completed, will make us fully compliant."
Staff training materials are being updated to include revised MRI safety screening procedures. Also, a preliminary remote screening is now done to ensure that patients with absolute contraindications to an MRI are not exposed to the magnet environment.
At St. Joseph's each MRI scanner is checked every day before patients are scanned, by performing scans for quality assurance. "This assures image quality and patient safety, and is also used to identify any potential scanner problem that could be fixed through preventive maintenance rather than scanner down time," says Karen Brown, education and quality coordinator for radiology services.
There is no formal image quality assessment, since the radiologist communicates quality concerns on a daily basis. For instance, if there is an artifact on the image that cannot be resolved with parameter changes, the field engineer would be called in to troubleshoot and fix the problem.
Brown does monthly MRI audits on the following indicators:
- pertinent patient records and forms scanned into the picture archiving and communications system;
- metal screen forms completed;
- contrast screening form completed;
- glomerular filtration rate documented;
- MRI progress notes for inpatients completed and signed;
- signed orders;
- orders include pertinent clinical indication;
- unreported procedures;
- the number of days reports were delayed;
- the number of exams not sent to billing within 24 hours of completion;
- turnaround times for reports;
- breakdown times to dictate, transcribed and final, by radiologist.
"The radiologists do monthly peer review for discrepancies, readmissions, and adverse outcomes," says Brown. "Daily, the department audits and reports exams older than 24 hours not dictated."
[For more information, contact:
Karen Brown, Education and Quality Coordinator, Radiology Services, St. Joseph's Hospital and Medical Center, 350 West Thomas Road, Phoenix, AZ 85013. E-mail: [email protected].
Deanne Roe, Director of Radiology, St. Joseph's Hospital and Medical Center, 350 W. Thomas Road, Phoenix, AZ 85013. E-mail: [email protected].
David A. Snyder, MD, Vice President of Patient Care Quality and Safety, MCGHealth, 1120 15th Street, BI-2081, Augusta, GA 30912. E-mail: [email protected].]
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