With around 8,000 – 10,000 MRI’s in the US alone, I’m not naive enough to think that we can wholly reshape behavior in all, or even a majority, of MRI providers in a single year. I do believe, however, that we can set a realistic goal to improve MRI safety.
It starts with the evidence that nearly all FDA reported MRI accidents fall into the ‘never event’ categories of projectiles, burns and hearing damage. These accidents aren’t complicated. They don’t typically require a five-year root-cause analysis to figure out why they happened. They happen either because something that should be there (padding or earplugs) isn’t, or because something that shouldn’t be there (ferromagnetic objects) is.
Human beings are fallible, myself at least as much so as anyone else. This applies to MR patients, visitors, transport, housekeeping, Technologists, Nurses, and even MD’s. To reduce MRI errors and accidents we need to supplement the skills of observation of MR staffers with affirmative checks, such as a pilot’s pre-flight run-down.
- Did Mrs. Jones pass the clinical-contraindication screening?
- Are there contraindications for contrast?
- Did she effectively change / gown / remove metal?
- Did she the clear the ferromagnetic detector without it alarming?
- Was the intercom explained to her?
- Was the squeeze ball explained to her?
- Was she given the squeeze ball?
- Was she positioned / padded so that she doesn’t contact the bore wall?
- Was she positioned / padded so that her body doesn’t form any large-caliber loops?
- Was she instructed about maintaining body position throughout the exam?
- Was she provided ear plugs / muffs?
- Was she instructed on the proper placement of hearing protection?
- Was she assisted in the proper placement of hearing protection?
If we did these 13 tasks, as appropriate, for anyone and everyone approaching the MRI magnet, we could eliminate the vast majority of MRI accidents.
This is at the crux of our ‘No More’ in ’09 commitment. By following this checklist of known and established best practices, we have the ability to stem the growing tide of MRI accidents. And while I would love to have 2009 be a wholly accident free year for MRI, we need to start first with reversing the trend of the last several years.
MRI accident reports have nearly tripled in the last several years. Before we can really begin to drive the number of accidents down, we first need to stop this growing hemhorrage of MRI injuries. ‘No More’ in ’09 means exactly what it says… we must work to see to it that the tally of MRI accidents for the coming year does not exceed the 2008 tally (which we should have in a month or so).
Of course, the easy way to reach this metric is to simply stop reporting those accidents that do happen, but not only is that in violation of the spirit of the commitment, it’s counter to the intention of the goal of reducing accidents. One reason that MRI accidents persist (and persist in great numbers) is that the lessons learned from one site’s accident are rarely shared with the larger MRI community.
So the goal is really two-fold. First, follow the best practices to eliminate MRI accidents at your site(s). Second, when there is a breakdown and an injury or near-event occurs, report it with as much detail as you can for the benefit of your colleagues around the world.
If we follow these steps, next year at this time we can reflect upon whether we have been able to improve the safety for MRI patients and staff. It’s not a question of whether we can. It’s only a question of whether we will.Tobias Gilk, President & MRI Safety Director Mednovus, Inc. Tobias.Gilk@Mednovus.com www.MEDNOVUS.com