2009 – The MRI Safety Year That Wasn’t

But 2010 holds the promise of reversing course.

Throughout 2009, we saw tantalizing glimpses of potential MRI safety improvements, which repeatedly escaped becoming real. Here are my ‘Top 3’ near-miss opportunities of 2009 to substantially reshape MR safety…

  • After failing to do anything with their Sentinel Event Alert #38 in 2008, JCAHO implemented an ‘Environment of Care’ standard which invoked SEA’s as a part of the required risk assessment, but failed to follow through on this rare 2nd opportunity.
  • Formally requested (by their own MR Safety Committee) back in 2006, at the AHRA annual meeting the ACR announced that it would implement safety requirements as a part of MR Accreditation. To date there’s no evidence that any real progress has been made in developing this standard.
  • The oft-delayed Colombini lawsuit, which held the promise of defining civil responsibility toward MR patient safety (since regulatory and accreditation standards appear lackluster, at best), fizzled in an ‘out-of-court’ settlement in October after some egregiously poor pre-trial decisions by the judge that largely absolved any individual responsibility for MR patient safety.

And yet, despite the barrage of setbacks, I am more confident about the year ahead than I have been before. ‘Why,’ you ask?

Starting January 12th, copies of the 2010 update for the Guidelines for Design and Construction of Healthcare Facilities (Guidelines, for short) will begin shipping. Guidelines is, in effect, the building code for hospitals throughout the US. The advanced draft I saw included MR safety design requirements, including the ACR 4-zone, line-of-sight situational awareness, and ferromagnetic detection. It will take many months for the various authorities having jurisdiction (AHJ’s) to adopt the 2010 edition of Guidelines, but the path to greater MR suite safety is clearly laid out in front of us.

Though getting MR safety into JCAHO surveyor training materials has been a non-starter for years, it looks as thought that’s about to end. SEA #38 on MRI accidents and injuries actually encapsulates some of the very best safety guidance available, and it appears as thought this year will be the first that JCAHO provides its surveyors with explicit training on the risks addressed in SEA #38.

In 2010 the ACR’s MR Safety Committee will be issuing an update to the Guidance Document for Safe MR Practices (the document originally known as the ‘White Paper on MR Safety’). Since the prior version, released in 2007, the American Society of Anesthesiology came out with their MR acuity levels which will hopefully be included as a part of the updated ACR document. This (and many other refinements) will help to tailor safety responses that are appropriate to the type and level of care provided.

The confluence of the other events should, in theory, make it much easier for the ACR’s MR Accreditation Committee to act on the now-four-year-old request to implement safety standards in the accreditation program.

Have you ever done one of those trust exercises where a number of people stand front-to-back in a tight ring, and everyone slowly sits down, putting their weight on the knees of the person behind them? 2010 now promises to be the year when Guidelines, JCAHO and the ACR (and, if we luck out, MR system manufacturers and the FDA) will form that ring.

Most bureaucratic regulatory / accreditation bodies dread being first, but long to be a quick second, in developing new standards.With the Guidelines document taking the first step, it will hopefully be much easier for JCAHO, ACR, and even the MR manufacturers and the FDA, to take ‘me too’ positions on MRI safety.

2010 holds tremendous promise for MR safety regulatory and accreditation improvements. A number of us will be working, diligently, to steer this herd of cats towards the goal of closing out 2010 with substantially more effective guidance / governance than 2009.

Here’s wishing each of you readers a healthy, happy, prosperous, and MR-accident free 2010!

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

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2 thoughts on “2009 – The MRI Safety Year That Wasn’t

  1. Pingback: Tweets that mention 2009 – The MRI Safety Year That Wasn’t « MRI Metal Detector Blog -- Topsy.com

  2. gene

    I have been asked to perform some minor inspection/construction work in a MRI room while the MRI machine is ramped up-ON position. On the MRI questionnaire I checked box “yes” for metal in the eye. The hospital will pay for the cost for eye X-ray at a different medical company, but will not assume the responsibility for performing the eye x-ray at the hospital in question..

    The hospital facility department is almost demanding this inspection/construction work be performed, yet they cannot produce a safety manual or procedure for this application. Can anyone assist???

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