5 MRI ‘Never Events’

For those unfamiliar with the term, a ‘never event’ is a label used to describe an adverse event that is wholly avoidable by simply following established best practices. For example, if you have an accurate count of the surgical instruments before and after surgery, there should never be an event where the patient leaves the OR with a sponge or clamp sewn up inside of them. A retained surgical instrument, or wrong-site surgery, or bed-sores, or patient mis-identification, or medication errors are all examples of ‘never events’.

Some insurance payers are beginning to refuse reimbursement for care that is necessitated by certain ‘never events’, and that list is likely to grow. And while they may not always result in patient injury, I’d like to propose my own list of 5 MRI ‘never events’ which should at least trigger an investigation…

#5 Unauthorized Access: If any person, patient, visitor or staff member, gains access to the restricted areas of the MRI suite (Zones III and IV) without having been appropriately screened and supervised, this should raise red-flags and be the impetus for a review of the physical protections and operational protocols. Too often, because these safety-symptoms don’t immediately result in injury, they are disregarded as harmless, which couldn’t be further from the truth. If unscreened people or equipment are making it into the controlled access areas of the MRI suite, it’s only a matter of time before one of them is involved in a real accident.

#4 NSF / Renal Function Screening: A year ago, this may have appeared as the #1 item on this list, but the fact is that, today, many facilities are doing a great job of this. Essentially, we need to provide, at a minimum, a renal function risk-factor screening for every patient prior to being administered Gadolinium-based contrast agents. And, minimally, for patients identified as falling within one of the higher-risk profiles, a calculated eGFR should be taken for verification of patient risk and to inform the treatment of that patient. As with the #5 never event above, the failure to provide effective screening, even if it doesn’t result in an adverse outcome, is enough to warrant a review of operational protocols.

#3 Contraindicated Implants: There are times when, as a concurrent result of poor patient history / records, and inconspicuous (or absent) indicators for medical devices, patients (or visitors) enter the MRI scanner room with contraindicated devices. Nobody expects MR Technologists to be omniscient about what is on or inside their patients, but it is critical that we provide an appropriately thorough screening for the circumstances to try and ascertain whether the patient has any of the potpourri of shunts, pacers, stimulators, clips, pins, plates, etc… that may be dangerous to them. Any failure to use the appropriate means available to identify contraindications should, minimally, spur an evaluation of policies & procedures.

#2 RF Burns: This one factor may be the fastest-growing source of patient injury in MRI. By verifying that unneeded coils and leads are removed, that remaining leads are appropriately positioned and insulated from the patient, that the patient’s body is not positioned to form large-caliber loops, and that there is appropriate distance / insulation between the patient and any transmitting RF coils are all integral, requisite elements to minimizing the risks of MR burns. A failure to follow the appropriate steps to protect the patient, even if the shortcut doesn’t result in a visible burn, should (as with the proceeding never events) trigger a review of operational procedures.

#1 Projectiles / Missiles: Screening protocols should do everything to make sure that ferromagnetic materials are not brought into the MRI scanner room. Any discovered ferromagnetic material inside the MRI room indicates a breakdown in screening and presents all of the ingredients for injury or equipment damage. Particularly for MRI providers that don’t gown all of their patients, the use of a ferromagnetic detector is more than just recommended, it is codified in the ACR Guidance Document for Safe MR Practices as a part of the MR safety best practice. And as with all of the MRI never events before #1, any discovery of a ferromagnetic threat inside the magnet room should trigger a review of existing protections, operations and protocols.

While these 5 don’t encompass all of MRI safety, they do clearly represent 5 of the most common (and most avoidable) hazards in the MRI environment. MRI providers should have rigorous protocols and protections to minimize these risks to patients, staff, visitors and, in the case of projectile accidents, millions of dollars of MRI equipment.

Tobias Gilk, President & MRI Safety Director
Mednovus, Inc.

4 thoughts on “5 MRI ‘Never Events’

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  3. Pingback: Can We Still Call Them ‘Never Events’ When Accidents Happen So Frequently In MRI? « MRI Metal Detector Blog

  4. Cyn

    An FDA advisory panel just recommended that the warning for Covidien’s Optimark and GE’s Omniscan—drugs in the family of medications known as gadolinium-based contrast agents (GBCAs)—be updated to restrict their use in patients with severe kidney disease because of the potential for an increased risk of nephrogenic systemic fibrosis (NSF). NSF causes thickening of the skin and organs. GBCAs carry a strong “black box” warning.

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