The ECRI Institute has again published their annual Top-10 Health Technology Hazards document for 2008, which is available as a free download from their website. Number 9 on the ECRI list is one of the well known MRI hazards. But before I tell you which MRI hazard made their list, let me give you a little background on what the ECRI Institute is and what they do…
ECRI Institute is a not-for-profit organization that provides evaluations of medical equipment and safety information for its members. They have a long history of following equipment safety issues, including MRI. They were the first (and only, as far as I’ve learned) organization that received a breakdown of the Pennsylvania Patient Safety Authority’s MRI incident reports, which they shared on a conference call in September of 2005. They also conducted a survey of their members to obtain a breakdown of the type and frequency of MRI accidents.
60% of those ECRI members that participated in the survey indicated that they had experienced a MRI projectile incident, about 16% indicated that they had a patient burn event, 11% indicated that they had an episode in which the MRI interfered with another device and roughly 13% indicated that they had other types of MRI safety incidents that weren’t appropriately categorized in the other classifications.
[By the way, information from MR safety experts who are often consulted in MRI injury cases suggests that the ECRI data is correct in defining the comparative order of frequency of MRI incidents.]
So, the ECRI Institute’s member data suggests that projectile incidents occur at nearly a 4:1 rate over burns, 6:1 over device interference and 5:1 over all other unclassified accidents, combined. So which MRI hazard made the Institute’s Top-10 list? Burns.
I do not fault ECRI for bringing attention to the issues surrounding RF burns and their prevention. As with projectiles, we conclusively know the causes of RF burns and the effective means to prevent them. A bright light should be shone on the issues of RF burn prevention to prompt providers to take the necessary steps to prevent what should be a ‘never event.’ But if we’re creating Top-10 lists, shouldn’t we pick the top items for the list?
Previously, Dr. Emanuel Kanal has characterized projectile threats in the MRI environment as ‘public enemy #1’ with regard to the safety of patients and caregivers. If we want to make the largest positive impact on MR safety, shouldn’t we tackle the greatest problems first (or at least concurrent with other hazards)?
“Number one injury in the MR environment today, thermal. Now I agree that that’s the number one reported adverse event, I’m not convinced that it’s the number one source of injury in MR environments. I believe that there may be many, many more projectile events still occurring that, if it’s serious enough, they try to settle without going to report and without going to trial.“
— Emanuel Kanal, MD, FACR, FISMRM, AANG (click here for the recording)
I applaud the ECRI Institute for its diligent and persistent attention to MRI safety issues. They have championed this focus at times when other organizations were largely silent. I agree that RF burns are a serious safety issue within MR, an issue that deserves immediate attention by MR providers. However, if the interest in publishing the Top-10 hazard list is to effect the greatest positive outcome in patient safety, shouldn’t we tackle the largest threat, ferromagnetic materials in the MRI suite, first?Tobias Gilk, President & MRI Safety Director Mednovus, Inc. Tobias.Gilk@Mednovus.com www.MEDNOVUS.com