Checklist for New Joint Commission Safety Requirements

While they released a Sentinel Event Alert on MRI safety in 2008, and while they’ve interpreted MRI-specific applications of a couple of hospital-wide standards (mainly, non-magnetic portable fire extinguishers), it was this past December (2013) when they announced their first explicit MRI Safety Standards, which become effective in July of 2014.

There are a few highly-specific criteria that don’t leave much to interpretation (collect data on your failed screenings in which a ferromagnetic object was allowed to enter the MRI scanner room), and there are more somewhat ambiguously-worded standards (manage MRI safety risks). Any facility that has undergone more than one Joint Commission survey knows that there is often different emphasis from one survey to the next, even if the standards haven’t changed. What follows is my own, personal, compliance checklist of the new MRI standards. While not reviewed / approved / sanctioned / blessed by the Joint Commission, I would contend that anyone who can check all of these boxes should sail through any survey that uses the new MRI safety standards…

First thing I would recommend is that you get your very own copy of the new standards, available HERE. In addition to having the specific language of the standards for MRI, you may also have other modalities (CT, or Nuclear Medicine) that are governed by the new standard, and you should familiarize yourself with those requirements, too.

OK, on to our checklist…

EC.02.01.01 is all about managing risks, and it’s these two Elements of Performance (EPs) that contain some of the more ambiguous language, when it comes to specific measures. But based on what these say, I would offer the following performance criteria:

  • Designate a physician MR Medical Director with the responsibility to review and approve MRI-specific policies and procedures.
  • Designate a technologist / radiographer / medical physicist as MR Safety Officer with the responsibilities of daily compliance with the MRI-specific policies and procedures.
  • Create (if you don’t have already) policies and procedures that:
    • Address strategies for calming or responding to the anxious or distressed patient, including where, when, and how medications for anxiety are to be handled.
    • Describe specific responses in the event of anticipated code events, including respiratory distress, cardiac arrest, slip-and-fall, contrast reaction, patient burn, projectile event, or magnet system quench.
    • Describe standard clinical screening protocols for the identification of medical devices or retained foreign objects in persons who are to be allowed to access the MRI scanning room.
    • Describe standard physical screening protocols for the identification of any and all objects and materials that may be ferromagnetic before they are allowed to access the MRI scanning room.
    • Describe your site’s requirements or recommendations relative to acoustic injury protection.
    • Describe the standard by which MR staff education (content, competency) is linked to independent access to a secured MRI suite.
  • Implement the access-control, and line of sight supervision, and staff training requirements of the ACR 4-Zone principle.
  • Provide warning signage about magnetic field hazards, as well as signage to indicate that the MRI scanner is always on.

EC.02.04.01 is about managing the risks specific to medical equipment.

  • Document (and follow) a schedule of maintenance and quality control activities for the MRI scanner.

EC.02.04.03 is about testing and maintaining medical equipment.

  • Follow a QA / QC plan to assure quality / consistency of clinical images (either one administered by someone else, or develop your own).
  • For MRI, this means (at least annually) that a physicist or MRI scientist is to document an evaluation of the equipment to include (minimally):
    • Image uniformity for all RF coils
    • Signal-to-Noise ratio for all coils
    • Slice thickness accuracy
    • Slice position accuracy
    • Alignment light accuracy
    • High-contrast resolution
    • Low-contrast resolution (contrast-to-noise ratio)
    • Geometric or distance accuracy
    • Magnetic field homogeneity
    • Artifact evaluation
  • Additionally, the console display monitors must be tested for
    • Maximum and minimum luminance
    • luminance uniformity
    • Resolution
    • Spatial accuracy

In short, if it’s a part of the MRI that is involved in capturing the image, or displaying it, make sure that you’ve got a plan to make sure that the bits are in working order, and stick to that plan.

HR.01.05.03 is about continuing education and training for staff.

  • Any MR technologist / radiographer who performs MRI studies is to receive (at least) annual MRI safety training. To these, I would add this requirement to anyone who has a responsibility for safety in the MRI (MR Medical Director, MR Safety Officer, Enterprise-level Safety Officer). This training is to include:
    • Screening for ferromagnetic threats
    • Screening for medial devices / implants
    • Screening for NSF risks (the ACR has developed a good list for identifying patients with risk-factors for reduced renal function, which might indicate eGFR testing)
    • Patient positioning to prevent burns (to this I would add screening for burn risks, and the use of padding / positioning aids, and coils to reduce burn risks).
    • Appropriate (MR Conditional) equipment and supplies for use in the MRI environment
    • Procedures in a code (to which I would add at least one code drill per year)
    • Emergency run-down procedures and protocols
    • Emergency quench procedures and protocols
    • Management of anxious or distressed patients

PC.01.02.15 This EP is about the necessity of providing diagnostic services at a hospital.

  • Prior to imaging the patient, verify:
    • Patient identify
    • Imaging site for the study
    • Patient positioning for the study
  • Additionally, the provider is to identify the patient’s age and the appropriateness of the modality / exam.

And if there were a desire to ‘cut corners’ on any of the above standards (or my additions to them), the ‘gotcha’ provision lies in PI.01.01.01, which is about monitoring and improving performance in the delivery of care…

  • Maintain a record of all patient burns that occur (or are purported to have occurred) during MRI exams.
  • Maintain a record of failed screenings for ferromagnetic objects / materials when these objects were unintentionally / unknowingly brought into the MRI scanner room (whether the object was attracted to the magnet or not).
  • Maintain a record of any and all injuries involving a ferromagnetic object in the MRI scanner room.

As I noted, the described protections in the standards to prevent burns and projectile accidents are pretty much, “try not to let these happen.” The language of TJC’s standards on these issues does not describe specific preventive actions that the provider could / should take, or the criteria by which surveyors will be evaluating the site.

MRI burn prevention involves screening the patient for electrically conductive materials, knowing the proper orientation / positioning / scanner or sequence selection to minimize these risks. Teaching techs positioning, yes, is important, but it – alone – won’t prevent burns. And since your facility will be required to record the burn incidents, you will be building a paper-trail for plaintiff / prosecuting attorneys if the facility doesn’t take a more comprehensive approach to preventing burns.

Similarly, the PI standard requires documenting not only projectile injuries, but also failed screenings for ferromagnetic materials… again, creating a paper-trail should you ever find yourself in litigation. While the only black-and-white standard preventive piece of the new standards says to ‘manage the risks of ferromagnetic objects’, I would strongly recommend that providers take the specific step to incorporate ferromagnetic detection systems in their preventative scheme.

I am pleased that TJC has issued these standards (and more than a little surprised that they’ve beat the ACR to the implementation of concrete MRI safety standards), but I think that the ambiguity and built-in liability risk with the documentation make it so that many providers will benefit from this checklist.

Tobias Gilk

19 thoughts on “Checklist for New Joint Commission Safety Requirements

  1. Stacey

    This should be a picture ALL hospital employees need to see, especially when some nurses insist they know your job better than you do & argues that their patient should be able to go in MRI scan room by way of the patients bed. (Not wanting the patient to be put on a stretcher that you have explained is MRI compatible)

  2. josephine

    nurses are the first ones to be sent for safety sessions. I encounter some of them strongly refusing to remove their hair pins while accompanying a critical patient into mri room.
    horrible situation for the Tech who is racing with clock.

  3. Tobias Gilk Post author


    The Emergency Rundown is essentially a ‘circuit breaker’ that cuts power to all of the RF systems. It does nothing to the magnetic field, but it cuts all the electrical power. This is the appropriate option if there’s a gradient overheating or risk of an electrical fire in the MR system components.

    The ‘quench button’, well… quenches the magnet. It activates a little heating element within the MRI scanner that starts a cascade reaction that triggers the quench. By ‘killing’ the superconductivity, the electrical energy that normally supported the magnetic field, is converted to heat. The result, you go from 1.5T to 0.001T (or something similarly small) in a matter of seconds.

    Like a circuit breaker at home, it is relatively easy to reset the emergency rundown unit, and be up and running in short order. The quench button, however…

    I hope this helps.

    Tobias Gilk

  4. David

    The term Emergency Rundown confused me. I know we just tested our the Magnet Rundown Unit for the recent GE recall and that contains the quench button. The Emergency Stop button cuts the power as you described on my GE equipment.
    Thanks for the info, great blog.

  5. Tobias Gilk Post author


    I need to correct myself. Different vendors have different names for the two function (quench vs. ‘circuit breaker’), and I believe that your questioning my answer is well founded. I don’t have the GE product information in front of me, but I think the Emergency Run Down is a GE term for the quench button (where Siemens, I believe, calls the ‘circuit breaker’ the Emergency Power Off (or “EPO”).

    Another instance where different terminology by different vendors can make even simple things more complicated. I hope I didn’t create too much confusion. Thank you for replying.


  6. Mary W

    Do you know if there is a standard template for documenting thermal burns, injuries involving ferromagnetic objects and/or failed screenings. The Joint Commission guidelines don’t really give us much direction.

  7. Tobias Gilk Post author

    Great question… but no, I’ve not seen anything from TJC that defines what format they’re looking for this information in.

    I’ve been advising clients to build a spreadsheet, even if it’s just printed pages on a clipboard, and have a process for this as you would for whatever other quality metrics you track. In my opinion, this should include:


      Anatomical location(s) of burn(s)
      Size and degree of burn(s)
      MRI exam (incl. sequences)
      Patient positioning for exam
      Technologist(s) involved in screening / positioning / scanning the patient
      Presumed source of burn

    Ferromagnetic Objects-

      Drawn to the MR scanner?
      Struck person(s) in any way?
      Technologist responsible for exam / room security
      Screening process used

    I hope this helps.


  8. Shannon

    What measures are you seeing facilities take in regards to MRI Tech annual safety education? Annual checklist, review of policy & procedure, etc…

  9. Tobias Gilk Post author

    In a couple of weeks from now, new Joint Commission requirements for MRI tech safety education will go into effect. These will include:

  10. Screening (worn / carried items, implants, NSF)
    Positioning to avoid thermal injuries
    Appropriate equipment / materials (MR Conditional)
    MR-specific code procedures
    Emergency shut-down (incl. quench) procedures
    Patient hearing protection
    Management of anxiety / claustrophobia
  11. In addition to documenting the above, I am a strong proponent of annual reviews of policy and procedure documents on MR safety practices, and code drills.

    I hope this helps.

  12. Tom

    What is the accepted criteria for safety screening in the non responsive or non compliant hospital patient.

  13. Tobias Gilk Post author

    The 2013 ACR Guidance Document speaks specifically to this situation:

    “Screening of patients for whom an MR examination is deemed clinically indicated or necessary, but who are unconscious or unresponsive, who cannot provide their own reliable histories regarding prior possible exposures to surgery, trauma, or metallic foreign objects, and for whom such histories cannot be reliably obtained from others:

    1. If no reliable patient metal exposure history can be obtained, and if the requested MR examination cannot reasonably wait until a reliable history might be obtained, it is recommended that such patients be physically examined by level 2 MR personnel. All areas of scars or deformities that might be anatomically indicative of an implant, such as on the chest or spine region, and whose origins are unknown and which may have been caused by ferromagnetic foreign bodies, implants, etc., should be subject to plain-film radiography (if recently obtained plain films or CT or MR studies of such areas are not already available). The investigation described above should be made to ensure there are no potentially harmful embedded or implanted metallic foreign objects or devices. All such patients should also undergo plain film imaging of the skull or orbits and chest to exclude metallic foreign objects (if recently obtained such radiographic or MR information not already available).”

    I hope this helps.


  14. Allison

    What are your thoughts on a 11 hr shift staffed with only one MRI tech and no aide? Roughly 8-10+ on average patients a day?
    Safety concerns?
    Thank you

  15. Tobias Gilk Post author


    There are so many potential variables in that question that it’s very difficult to answer in the abstract. In general, though, I agree with the ACR Guidance Document and I think there should be a second MR-safety trained individual there to support the scanning tech.

    I hope this helps.


  16. Karen

    Our facility does a quarterly mock drill fire code. I have talked to other facilities and they also do a mock code blue drill for MRI. Is this something that we need to implement doing also. If so, are there specific requirements from JC on these and what are they?

  17. Tobias Gilk Post author


    To the best of my knowledge, TJC does not have explicit MRI-specific code drill requirements. However, I do believe that they require ‘appropriate’ code drills, which could be interpreted to have a specific purpose for MRI. I very strongly recommend to my consulting clients that they regularly run (at least semi-annually) code blue drills for MRI. If the drill can be run unannounced, even better.

    I hope this helps.

  18. Kathryn

    I work at a facility at which I was told there is no need to research any leg stents, as they are all safe with a 1.5T unit. How accurate is this?

  19. Tobias Gilk Post author


    The only categorical MR clearance for a device type that I’m aware of is for coronary stents. This has been offered by Dr. Kanal, and then by Dr. Shellock. Both of them have been very explicit in statements that their categorical clearance applies to only coronary stents, and not to other stents, specifically citing some overtly ferromagnetic large vessel stents.

    This does not mean that only these two people can develop / issue categorical MR clearances, or that scanning an unidentified large-vessel stent will result in injury. If the supervising physician at the site has a written policy with respect to categorical clearances, then s/he is effectively taking responsibility for the risk assessment of all covered devices. I’m not aware that such a position has literature support, and I’m unaware of any other sites that have similar categorical exceptions for large vessel stents.

    I hope that helps.

  20. Billy

    Thank you so much for sharing this information. So important to keep in mind these safety requirements for this magnetic industry. Looking forward to seeing how this develops.

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