Tag Archives: MAUDE

Radiation Therapy Accidents vs. MRI Accidents

I stumbled across a paper abstract from the International Journal of Medical Physics Research and Practice. The abstract described a meeting on radiation oncology safety which, “attracted 400 attendees, including medical physicists, radiation oncologists, medical dosimetrists, radiation therapists, hospital administrators, regulators, and representatives of equipment manufacturers. The meeting was cohosted by 14 organizations in the United States and Canada.”

Damn! I’m impressed, particularly since the abstract also states that this meeting was hastily called in response to articles appearing, starting in January of this year, in the New York Times on radiology and radiation therapy accidents. Such a coordinated response by the professional societies. Such representation from the professional community at a time when conference and professional development budgets are being slashed. How does this compare with MRI?

Click To Read How The Two Compare…

‘Learn The Things You Don’t Know That You Don’t Know.’

This, in essence, is the entirety of point-of-care safety standards for MRI.

Hey, you, MR technologist! Make sure you know what you’re supposed to know to keep people safe around MRI.

Make no mistake, as someone who spent a decade in college (which included a Masters degree and about half of a 2nd Bachelors), I’m a huge fan of education. What I’m adamantly opposed to – when it comes to MRI safety – is education without any standards or benchmarks, which is precisely where we find ourselves today.

Click To Read What Tobias Thinks Is Wrong With MRI Safety Training…

NOT Magnet Safe Scissors!

Last year I highlighted an FDA MRI accident report in which a technologist had to have a pair of scissors surgically removed from his forehead after they’d caught him between the magnet-homing missile that they became, and the isocenter of the MRI. You may remember that I fauxtoshopped a hypothesis as to what that accident would have looked like on plain film: perhaps something like this… Click For More On What This Accident Was Like…

MRI Accident Rates: It’s Not As Bad As Previously Reported…

IT’S WORSE!

That’s right, the FDA has updated it’s MRI accident figures available online through the MAUDE database. We were alarmed and astonished when we thought that the rate of increases in MRI accidents was only 270% (from 2004 to 2008). Turns out that the FDA must have found additional accident reports that were in a stack of junk-mail, or got lost between the sofa cushions, which means that the rate if adverse events went up, significantly, in 2008 from the prior calculation.

Click Here To Learn How Much Worse MRI Accident Rates Really Are…

MRI Projectile Accidents – One Exemplar

How to pick just one when there are a number of alarming, tragic, and needless MRI accidents to choose from? Let’s look at one that we can help the reader better imagine, the case of a pair of flying scissors that had to be surgically removed from a technologist’s forehead…

Click For The Rest Of This Story…

Gurney Crashes MRI, Patient Injured, Hospital Fined $50K

It is the stuff of fabled oral-histories, often dismissed as MRI urban-legend. The patient is wheeled into the MRI room on a gurney that goes flying toward the scanner. “How on Earth could these accidents happen when we know about these risks,” the skeptics question? Almost never does more than a single fragment of information surface about these sorts of accidents and, without verification, nearly all accounts can be erroneously written-off as fiction. Or, that was until enough pieces fell into place to conclusively document a recent episode… Click Here To Read More About MRI Gurney Accidents…

Can We Still Call Them ‘Never Events’ When Accidents Happen So Frequently In MRI?

This post attempts to draw-together two recent threads from here on the MRI Metal Detector blog. First, there was a long-running question about the FDA and their online-accessible database of medical device accidents which, for months, appeared to be malfunctioning, and recently was repaired. Second, there was my post in which I identified 5 MRI ‘Never Events’ which, if industry standard procedures are followed, should never occur.

Click For Several Recent Examples Of MRI Never Events…

FDA’s MAUDE Database Appears To Be Restored

For a couple of months, at least, the FDA’s MAUDE database wasn’t displaying all of the accident narratives online… This appears to have been fixed!

A number of the MRI accident reports, when the narratives weren’t appearing, were little more than the name and mailing address of the MRI manufacturer. Today, if you want to read about the MR Technologist who had a pair of scissors magnetically-impelled into his forehead, you can do so. So Click Here If You’re Curious…

Has FDA ‘Dumbed-Down’ MAUDE Accident Database?

I like to keep my finger on the pulse of MRI accidents and safety issues. One consequence of this is that I frequent the FDA’s MAUDE database (MAUDE is a tortured acronym for medical device user-reported mishaps). I have long criticized the FDA for their half-hearted efforts at collecting MRI accident data (which, in fairness, appears to be as much a product of congressional limitations on the FDA’s power as anything else), but MAUDE has been the only national database for these accidents that is publicly accessible.

Every so often there is an MRI accident description that is so stunning that it sends a jolt through me, reminding me why I do what I do. This is the entry that I came across just two weeks ago…

Click Here For The Jolting Description…

RT-Image’s August 3 Issue on MRI Safety

RT-Image brought a stack of their August 3rd issue to the AHRA and handed them out at the MRI safety presentation. Why (apart from general publicity)? Because the primary thrust of the issue was on many aspects of MRI safety. This issue has feature articles on the new MR Conditional pacemaker, infection control in the MRI suite, and even one that I wrote for them…

Click Here For A Link To Tobias’ Article For RT-Image…