This past weekend I had the privilege of participating in OSU MRI conference. I was able to sit-in on a number of the presenters, plus I presented, and was asked to sit-in on a panel discussion on safety with Bill Faulkner and Candi Roth. The conference provided me the opportunity to hear from a number techs regarding their most recent Joint Commission surveys, and I was encouraged by what they had to say.

My (longstanding) prior criticism of the Joint Commission and their MRI patient safety survey efforts have centered around one simple fact… they didn’t do anything with respect to MRI safety. JCAHO hasn’t ever had MRI-specific standards or survey criteria, but I was certain that the 2008 release of Sentinel Event Alert #38 on MRI accidents and injuries would change that, instantaneously (a SEA being the Joint Commission’s ultimate patient safety warning). It didn’t.

I was certain that the change to the Joint Commission’s 2009 changes to their Environment of Care (EC) standard which specifically invoked Sentinel Event Alerts would immediately change their survey methods. Reports I received from JCAHO accredited providers who were surveyed in the first half of 2009 indicated that I was to be disappointed again. But at the OSU conference, the clouds parted and glorious beams of hope shot down from the sky and landed on me.

Yes, I did hear several of the expected ‘their shadow never crossed our doorway’ stories of JCAHO surveyors ignoring MRI. There were also the accounts of ‘checked fire extinguisher and walked out.’ As little as one year ago, I would have expected that to be the end of the list, but several people came up to me and recounted recent surveys in which Joint Commission surveyors asked about…

• Screening forms
• ACR four-zone separations
• MR Conditional equipment
• Infection control procedures
• Emergent / code procedures, and,
• Ferromagnetic screening

One person told me of how the surveyor spent more than 30 minutes in their department, tracing the entire sequence of the screening and care of an MRI patient.

These heartening stories of surveyor attention to MRI were the minority, but given that JCAHO surveys occur on a 3-year interval, that there was any change in the status quo in the past year is likely an indicator of a significant prioritization of MRI safety at the Joint Commission.

The hazards of MRI come from the fact that – as soon as you step into that room – the fundamental laws of physics change, without any outward indication. Non-ferromagnetic objects still fall down, but ‘gravity’ works in a different direction for magnetic materials. This simple, invisible truth requires a host of MRI-specific safety protocols. Application of generalized hospital-wide patient safety standards to MRI hasn’t worked terribly well (as in, not at all) in the past, so I can’t tell you how encouraged I am by this recent news.

If one is truly interested in patient safety, and has been critical of others for a lack of attention to these issues, there is no sweeter sound than to hear that you are wrong. When weighed against the benefits to be realized by MRI patients, staff and providers from enhanced safety (fewer accidents), any swelling of my personal ego is of zero importance. I hope that the degree of my wrongitude only grows from here going forward.

‘On the Joint Commission,’ I should add. I do have my weekly PowerBall lottery ticket, and I would very much love to be right on that.

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This phrase isn’t meant to make anyone feel small. It doesn’t mean “you should know,” or “everybody else knows this,” or even that “the guy writing this knows.” This phrase is very democratic… it applies to each of us (particularly the guy writing this).

What it means is that, if our brains are libraries, even big ones, there’s only so much information that can fit inside. We may know the next 10, 100 or 1,000 books we want to add to our mental Alexandria, but we can’t want (or even hate) the book that we don’t know exists. The same is true of MRI safety.

We think that MRI accidents come from a limited menu; burns, projectiles, screening misses. The fact is that the contributing factors to any one accident often include a combination of operational, training, clinical and physical considerations.

Perhaps the most dangerous response to the potential of any MRI accident is, “oh, that can’t happen here because we’ve done ________,” as if any one factor is enough to eliminate the risk of accidents. The fact is that all protections fail.

“What about a suite with two trained Technologists and an MD immediately available? Surely we can rule out staff problems, right?”

“For our anesthesia cases, we have medical gasses piped into the room, so that risk goes away, right?”

“We don’t share the MRI suite with other modalities, so access from unscreened or unauthorized personnel isn’t a risk, right?”

Would you be surprised to learn that the suite where the most infamous MRI fatality occurred had two on-duty Techs, an MD in the suite, piped-in medical gasses, and a dedicated MRI suite?

Each of these are partial protections, and each of these can fail. What happens if your staff isn’t effectively trained (not what they can recount on a ‘quiz’, but the behaviour they would exhibit in an emergent situation)? What if the oxygen supply stops? What happens if an unscreened / unauthorized person enters the suite?

It’s ‘Murphy’s Law’… everything breaks down and the thing you depend on most will break down when you need it the most. The same applies to your MR suite safety features, which is why one is never enough for any risk factor.

Some decry layers of protection as redundant. I mean, do we really need 4-zones? What about ferromagnetic detection?

Have you played the ‘what if’ game? What if there are holes in your MRI safety net? What if transport circulates the door access code? What if engineering responds to a faulty smoke detector alarm at 4 am? What if the new guy in housekeeping wants to make a good impression by buffing the magnet room floor, even though nobody asked him to? What if a patient codes while one tech is taking a bathroom break? What if you find a pacemaker on a scout scan?

We don’t need reinforced frames, seatbelts, or airbags in order for our cars to take us from point a to point b. Similarly, in the strict sense we don’t really need MRI safety in order to have MRI imaging.

But just as if we stripped our cars of the safety glass, crumple-zones and eliminated crash-tests, we would imperil MRI imaging if we didn’t protect our providers and patients with fundamentals such as access controls, comprehensive screening and ferromagnetic detection.

Just because you don’t know what you don’t know, doesn’t mean you can’t learn it.