The Athens, Alabama, News Courier ran a story December 4th on their website about a 21-month boy who received a 3rd degree burn from an MRI. This hits square in the middle of the 5 MRI ‘never events’ that were enumerated a few months ago here on this blog.
The article describes how the boy was wrapped in a metallic ‘space blanket’ during the exam, and yet the 3rd degree burn was attributed (by the hospital administration) to ‘trapped heat’ in the cotton blanket that came from a blanket warmer.
Though it may have taken a little ‘nudging’ to get a formal commitment on the part of the hospital to cover the costs of all treatment associated with the burn, it is the least that should be done to offset the injury that was caused by a failure to follow industry standard screening protocols.
Hopefully this incident will also trigger a review of MRI protocols and procedures at this facility, too. Often the ‘it’ll never happen here’ attitude persists even after an incident (morphing, ever so smoothly, into ‘it’ll never happen here again‘), with little effectively done to reduce the risks of recurrence.
And as I am a firm believer in the gold-plated opportunity that is presented every time we learn of any mistake (our own or others’), I hope that MRI providers around the world look at this incident as one more validating event that periodic reviews of our safety policies is not just a good idea, it’s absolutely necessary in such a dynamic area as MRI.Tobias Gilk, President & MRI Safety Director Mednovus, Inc. Tobias.Gilk@Mednovus.com www.MEDNOVUS.com