Def.  Hyperbolic:  Rhetorical exaggeration or diminishing beyond the fact; exceeding the truth; as, an hyperbolical expression.

I have this sense that some feel that virtually all talk of MRI accidents is hyperbolic, or exaggeration. To those who believe this, I say there is a truth buried in this thought, but it’s not what they may think…

Flash back to high school when I simultaneously learned the alternate definitions for hyperbole. Mrs. Mayer, my English composition teacher taught that it was taking a truth and exaggerating it to just this side of the breaking point. Ms. Bohne, my geometry teacher, taught that the same word was used to describe mathematical curves which, as an example, were revealed in the cross-section of conical structures.

To those who feel that talk of the risks and costs of accidents in the MRI suite are exaggerated, I offer you Ms. Bohne’s hyperbola in response, as provided by the FDA’s accident data.

MRI Accident Rates As Reported To The FDA

The trend in these reports of accidents is both a marked increase over the last 4 years, as well as a marked acceleration in the growth rate.

It would be worrisome enough if this were just a straight-line function, exceeding as it does any rational explanation for ‘natural’ growth in accidents resulting from increased MRI utilization, but the fact that the year-over-year rate of accidents is accelerating should have the radiology and patient safety realms in an uproar.

The above graph may look familiar to you, as I’ve published prior versions of it before the 2008 data was available. The acceleration pattern was strongly suggested in last year’s numbers, but appears confirmed in the full 2008 figures.

What do these numbers mean? They mean that we’re unnecessarily injuring a significantly greater proportion of MRI patients today than we were just a few years ago.

I say ‘unnecessarily’ because we know the causes of the most prevalent MRI accidents (projectiles, device interference, burns, tinnitus) and we know how to dramatically attenuate the risks (ferromagnetic detectors, thorough screenings, effective patient positioning, hearing protection).

If the MRI industry were to follow the best-practice standards outlined in the ACR Guidance Document for Safe MR Practices, I would expect that the rates of MRI accidents would take a dramatic nose-dive. Nearly every accident in the FDA’s 2008 record might have been avoided through the proper use of the four interventions listed above.

Concern about MRI accidents can not possibly be hyperbole when the growth in accidents appears hyperbolic.

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.

It starts with the evidence that nearly all FDA reported MRI accidents fall into the ‘never event’ categories of projectiles, burns and hearing damage. These accidents aren’t complicated. They don’t typically require a five-year root-cause analysis to figure out why they happened. They happen either because something that should be there (padding or earplugs) isn’t, or because something that shouldn’t be there (ferromagnetic objects) is.

Human beings are fallible, myself at least as much so as anyone else. This applies to MR patients, visitors, transport, housekeeping, Technologists, Nurses, and even MD’s. To reduce MRI errors and accidents we need to supplement the skills of observation of MR staffers with affirmative checks, such as a pilot’s pre-flight run-down.

1. Did Mrs. Jones pass the clinical-contraindication screening?
2. Are there contraindications for contrast?
3. Did she effectively change / gown / remove metal?
4. Did she the clear the ferromagnetic detector without it alarming?
5. Was the intercom explained to her?
6. Was the squeeze ball explained to her?
7. Was she given the squeeze ball?
8. Was she positioned / padded so that she doesn’t contact the bore wall?
9. Was she positioned / padded so that her body doesn’t form any large-caliber loops?
10. Was she instructed about maintaining body position throughout the exam?
11. Was she provided ear plugs / muffs?
12. Was she instructed on the proper placement of hearing protection?
13. Was she assisted in the proper placement of hearing protection?

If we did these 13 tasks, as appropriate, for anyone and everyone approaching the MRI magnet, we could eliminate the vast majority of MRI accidents.

This is at the crux of our ‘No More’ in ’09 commitment. By following this checklist of known and established best practices, we have the ability to stem the growing tide of MRI accidents. And while I would love to have 2009 be a wholly accident free year for MRI, we need to start first with reversing the trend of the last several years.

MRI accident reports have nearly tripled in the last several years. Before we can really begin to drive the number of accidents down, we first need to stop this growing hemhorrage of MRI injuries. ‘No More’ in ’09 means exactly what it says… we must work to see to it that the tally of MRI accidents for the coming year does not exceed the 2008 tally (which we should have in a month or so).

Of course, the easy way to reach this metric is to simply stop reporting those accidents that do happen, but not only is that in violation of the spirit of the commitment, it’s counter to the intention of the goal of reducing accidents. One reason that MRI accidents persist (and persist in great numbers) is that the lessons learned from one site’s accident are rarely shared with the larger MRI community.

So the goal is really two-fold. First, follow the best practices to eliminate MRI accidents at your site(s). Second, when there is a breakdown and an injury or near-event occurs, report it with as much detail as you can for the benefit of your colleagues around the world.

If we follow these steps, next year at this time we can reflect upon whether we have been able to improve the safety for MRI patients and staff. It’s not a question of whether we can. It’s only a question of whether we will.

No, not me, the author, but the figurative ‘me‘, this blog…

I don’t know if you’ve ever used them, but all of the major internet search engines have tools that you can use to find images that match your search criteria. Every so often there’s a new paparazzi picture of some starlet in mid-wardrobe-malfunction or a politician with a facial expression that looks like they just smelled something awful that become the ‘it’ picture of the day.

Well, based on the number of hits our blog has been getting recently, and the image search tools that many of these hits are coming from, apparently we have a lesser ‘it’ picture, and it has nothing to do with politics or racy nudity…

It’s a picture of an ICU bed stuck to the face of an MRI.

Pictures of things stuck to magnets often generate wide-eyed looks, even laughter. After all, the juxtaposition can be pretty silly. But each of these pictures is only possible because of horrible mishaps that can each result in serious injury, or even fatality.

We encourage people to find and view these pictures, not to have a larger number of viewers snicker at them. We put them up to help deflate the ‘that could never happen here’ mythology that is dangerous. If you can see magnets, floor polishers, oxygen cylinders, wheelchairs or, as above, ICU beds that look like ones in use at the hospital or imaging center, then maybe the internal monologue becomes something more like, ‘what would have to happen here for us to have a similar accident?’

Most importantly, we hope that all of these efforts work to motivate Technologists, Radiographers, Imaging Managers, Radiologists, Risk-Managers and Compliance Officers to imagine which steps they could take at their locations to reduce the likelihood of these sorts of accidents.

There are many steps that can be taken to help improve the effectiveness of pre-screening for magnet hazards. One of the most obvious is also one of the easiest, the use of ferromagnetic detectors.

We encourage you to view and share the information contained on these pages and we hope that each of these resources, even the racy pictures of MRI missile accidents, help shape improvements to MRI safety at your facilities.

After all, I’m lot more than just a pretty face…