<?xml version="1.0" encoding="UTF-8"?>
<rss version="2.0"
	xmlns:content="http://purl.org/rss/1.0/modules/content/"
	xmlns:wfw="http://wellformedweb.org/CommentAPI/"
	xmlns:dc="http://purl.org/dc/elements/1.1/"
	xmlns:atom="http://www.w3.org/2005/Atom"
	xmlns:sy="http://purl.org/rss/1.0/modules/syndication/"
	xmlns:slash="http://purl.org/rss/1.0/modules/slash/"
		xmlns:itunes="http://www.itunes.com/dtds/podcast-1.0.dtd"
	xmlns:media="http://search.yahoo.com/mrss/"
>

<channel>
	<title>MRI Metal Detector Blog &#187; MR</title>
	<atom:link href="http://mrimetaldetector.com/blog/tag/mr/feed/" rel="self" type="application/rss+xml" />
	<link>http://mrimetaldetector.com/blog</link>
	<description>Info on ferromagnetic detection and MRI safety &#38; screening</description>
	<lastBuildDate>Tue, 27 Dec 2011 18:38:54 +0000</lastBuildDate>
	<language>en</language>
	<sy:updatePeriod>hourly</sy:updatePeriod>
	<sy:updateFrequency>1</sy:updateFrequency>
	<generator>http://wordpress.org/?v=3.3</generator>
	<copyright>2006-2007 </copyright>
	<managingEditor>tobias.gilk@mednovus.com (MRI Metal Detector Blog)</managingEditor>
	<webMaster>tobias.gilk@mednovus.com (MRI Metal Detector Blog)</webMaster>
	<image>
		<url>http://mrimetaldetector.com/blog/wp-content/plugins/podpress/images/powered_by_podpress.jpg</url>
		<title>MRI Metal Detector Blog</title>
		<link>http://mrimetaldetector.com/blog</link>
		<width>144</width>
		<height>144</height>
	</image>
	<itunes:subtitle></itunes:subtitle>
	<itunes:summary>Info on ferromagnetic detection and MRI safety &#38; screening</itunes:summary>
	<itunes:keywords></itunes:keywords>
	<itunes:category text="Society &#38; Culture" />
	<itunes:author>MRI Metal Detector Blog</itunes:author>
	<itunes:owner>
		<itunes:name>MRI Metal Detector Blog</itunes:name>
		<itunes:email>tobias.gilk@mednovus.com</itunes:email>
	</itunes:owner>
	<itunes:block>no</itunes:block>
	<itunes:explicit>no</itunes:explicit>
	<itunes:image href="http://mrimetaldetector.com/blog/wp-content/plugins/podpress/images/powered_by_podpress_large.jpg" />
		<item>
		<title>MRI Safety, Per ACR Accreditation Standards</title>
		<link>http://mrimetaldetector.com/blog/2011/05/mri-safety-per-acr-accreditation-standards/</link>
		<comments>http://mrimetaldetector.com/blog/2011/05/mri-safety-per-acr-accreditation-standards/#comments</comments>
		<pubDate>Sun, 15 May 2011 16:53:35 +0000</pubDate>
		<dc:creator>Tobias Gilk</dc:creator>
				<category><![CDATA[Other MRI Safety]]></category>
		<category><![CDATA[accidents]]></category>
		<category><![CDATA[accreditation]]></category>
		<category><![CDATA[ACR]]></category>
		<category><![CDATA[adverse event]]></category>
		<category><![CDATA[American College of Radiology]]></category>
		<category><![CDATA[CMS]]></category>
		<category><![CDATA[FDA]]></category>
		<category><![CDATA[imaging]]></category>
		<category><![CDATA[Medicaid]]></category>
		<category><![CDATA[medical]]></category>
		<category><![CDATA[Medicare]]></category>
		<category><![CDATA[MIPPA]]></category>
		<category><![CDATA[MR]]></category>
		<category><![CDATA[MRI]]></category>
		<category><![CDATA[quality]]></category>
		<category><![CDATA[radiation]]></category>
		<category><![CDATA[radiology]]></category>
		<category><![CDATA[safety]]></category>

		<guid isPermaLink="false">http://mrimetaldetector.com/blog/?p=971</guid>
		<description><![CDATA[When is MRI safety NOT in a radiology professional society's best interest? That's a great question, and one that we're still wrestling with the American College of Radiology to try and find out...]]></description>
			<content:encoded><![CDATA[<p>&#8220;Peachy Keen!&#8221;</p>
<p>One can only presume that this is the commentary that US States and radiology accreditation agencies have to offer on the contemporary state of MRI safety. After all, there&#8217;s been nothing more than navel-gazing when it comes to measurable changes in standards for MRI providers. Let&#8217;s break it down&#8230;</p>
<p><span id="more-971"></span>This first installment will look specifically at MRI safety standards as implemented by the American College of Radiology (ACR). By tackling them, first, I don&#8217;t mean to suggest that they&#8217;re the only concern with respect to MRI safety. In fact, in a weird, schizophrenic way, ACR has simultaneously advanced and held back MRI safety. More on that towards the end of this piece.</p>
<div id="attachment_980" class="wp-caption aligncenter" style="width: 310px"><a href="http://mrimetaldetector.com/blog/wp-content/uploads/2011/05/Gilk_2010_ACR_Quality_Safety.004.jpg"><img class="size-medium wp-image-980" title="MRI Accident Rate Slide from ACR Quality &amp; Safety Forum 2010" src="http://mrimetaldetector.com/blog/wp-content/uploads/2011/05/Gilk_2010_ACR_Quality_Safety.004-300x225.jpg" alt="MRI Accident Rate Slide from ACR Quality &amp; Safety Forum 2010" width="300" height="225" /></a><p class="wp-caption-text">MRI Accident Rate Slide from ACR Quality &amp; Safety Forum 2010</p></div>
<p>The American College of Radiology has distinguished itself with the premier industry best practice publication on MR safety, the <em>Guidance Document for Safe MR Practices</em>. Originally named the <em>White Paper on MR Safety</em> (published in 2002), its name switched to the <em>Guidance Document</em> with a 2004 update. I was fortunate enough to be a part of the ACR&#8217;s MR Safety Committee (the authoring body) for what became the 2007 edition.</p>
<p>When the Committee met at the ACR headquarters in the late summer of 2006, to review drafts and collectively decide on the final revisions, it was noted that the ACR&#8217;s contemporary MR accreditation program didn&#8217;t actually require any of the safety provisions found in the (then twice published) <em>Guidance Document</em>. In that meeting, five years ago, the MR Safety Committee unanimously voted to formally request that the ACR incorporate safety provisions found in the <em>Guidance Document</em> in the MR accreditation program (this was frightfully easy since the representatives of the College were there in the room with us).</p>
<p>Surrounding that Committee meeting in 2006, Nephrogenic Systemic Fibrosis (NSF) was the hot topic in MR safety. The radiology community and trade press were trading speculation, recrimination, and early analyses. The 2006 <em>Guidance Document</em> was held until it could be published with the collected best available information regarding NSF, which meant that it wasn&#8217;t released until early 2007.</p>
<p>Perhaps the ACR was waiting for the new <em>Guidance Document</em> to be released, I thought, so they didn&#8217;t implement any of the safety requirements in their MR accreditation program prior to the new version&#8217;s publication. So the rest of 2006 came and went, as did all of 2007, without so much as a hint that the MR Accreditation program would include the <em>Guidance Document</em>&#8216;s safety standards. Nearly all of 2008 passed the same way, with no indication that the ACR intended to include it&#8217;s own MRI safety standards in its accreditation requirements. But things showed promise of moving forward at the 2008 RSNA meeting.</p>
<p>I learned that the ACR&#8217;s MR accreditation committee was entertaining the notion of including some elements of the <em>Guidance Document&#8217;</em>s safety standards and that they had asked one of their physicists (not anyone from the MR Safety Committee) to draft a checklist set of safety standards. Purportedly, at that 2008 RSNA meeting, it was proposed that the 30+ page <em>Guidance Document</em> be distilled to about a half-dozen check-box question. One could argue that &#8216;something was better than nothing&#8217;, but the notion that these questions actually captured the essential safety elements of the <em>Guidance Document</em> was laughable. It didn&#8217;t fly. Back to square one.</p>
<p>Fast forward about a year, to summer 2009, when, at the AHRA annual meeting, representatives from ACR were giving a status update about accreditation standards. It was a packed meeting as the writing was on the wall about CMS requiring modality accreditation through the new MIPPA law. In that presentation, the ACR representatives stated that ACR would be incorporating elements of the <em>Guidance Document</em>&#8216;s safety principles in the MR Accreditation program. Precisely how this was to happen was yet to be determined, but it would happen.</p>
<p>In early 2010 CMS announced that the ACR would be one of three approved accreditation bodies to accredit imaging providers&#8217; CT, PET, and MRI scanners to qualify for reimbursement under the MIPPA law.</p>
<p>I was tremendously optimistic that this new requirement status would help to remove the concern within the ACR that implementing safety standards, unilaterally, would make other accreditation programs comparatively easier, and therefore more appealing to MRI providers. Now providers would be required to get accreditation, and ACR was clearly the front-runner in modality accreditation of the three named agencies. I called the ACR and spoke with a senior person within the organization about the safety standards. That person quickly burst my bubble&#8230;</p>
<p>Despite the public promise to incorporate elements of the <em>Guidance Document</em> from the prior year, in 2010 the ACR representative told me there would be no such plan going forward <em>because</em> they were now an approved accrediting body under the MIPPA law. According to this person, it was determined that it would be far too &#8216;bureaucratically burdensome&#8217; to have to go through CMS (a step which would be required for any change to the accreditation structure, now that it was CMS sanctioned) to update it&#8217;s standards to include the safety elements in the <em>Guidance Document</em>. The irony of a federal law mandating quality and safety standards being the reason that an accrediting agency claimed it couldn&#8217;t enact safety standards wasn&#8217;t lost on me. Fortunately, I was just about to get the chance to talk with the principal radiology quality and safety person at CMS to let her know what I thought of their safety-inhibiting bureaucracy.</p>
<p>In the summer of 2010, I was a participant in a joint presentation on MRI safety between the FDA and CMS.  One of the CMS representatives in that presentation was Jeannie Miller, Deputy Director of the Clinical Standards Group. After that presentation, I followed up with Ms. Miller and asked her about the ACR contention that it was now too &#8216;burdensome&#8217;, because of their new role with CMS, to add safety standards to their existing MR Accreditation program. In a word, Ms. Miller was incredulous.</p>
<p>She told me that, just a few weeks prior to our conversation, the ACR had submitted their breast MR accreditation program to CMS for their approval. How long did the &#8216;burdensome&#8217; CMS bureaucratic review take for this new and unprecedented MR accreditation program? Less than two weeks! Ms. Miller was dumbfounded at the suggestion that CMS would make it anything but easy for a quality and safety standard to enhance its safety components. So, if CMS &#8216;burdensome bureaucracy&#8217; is just a smoke screen, what&#8217;s the real reason ACR is unwilling to heed the recommendation of their own MR Safety Committee, and honor the promise they made two years ago, to incorporate substantive safety requirements in their MR Accreditation program? Could it be money?</p>
<p>Though ACR is one of the accrediting bodies from which CMS mandates that outpatient participants must obtain accreditation, it&#8217;s still one of three. While ACR is seeking to &#8216;make the pie bigger&#8217; by advocating for mandatory accreditation of more modalities than just CT, MRI, and PET <em>and</em> for accreditation of hospital-based imaging, nuclear medicine and radiation therapy, they&#8217;re also looking at their proportional slice of that pie. Were they to unilaterally decide on MR safety enhancements to their accreditation program, it <em>might</em> make providers looking for the lowest-threshold CMS accreditation steer clear of ACR. I suspect that the ACR&#8217;s thinking goes that, by enacting MR safety standards, they&#8217;re likely to lose prospective members and the revenue that their participation in the ACR&#8217;s accreditation program provides.</p>
<p>So we&#8217;re left with this profound contradiction presented by the ACR. One one hand, they have produced the industry&#8217;s best MRI safety best-practice document. On the other hand, they&#8217;re playing &#8216;see no evil, hear no evil, speak no evil&#8217; when it comes to implementing the real-world safety benefits that their own Guidance Document.</p>
<p>And it&#8217;s not as if the ACR has any doubts about the value of the Guidance Document&#8230; as a safety tool. They have brought together many of the best minds on MR safety, four times now (the 4th release of the <em>Guidance Document</em> is likely to come out in the 2nd half of 2011). The MR Safety Committee lead the charge in disseminating best practice standards relative to NSF screening. And at the ACR&#8217;s own radiology quality and safety forum, last year, they were presented with a paper jointly authored by their own MR Safety Committee chair, Dr. Emanuel Kanal, and me, which showed that the explicit provisions in the Guidance Document could mitigate at least 80% of the clinical MRI accidents (see the video of that presentation, <a href="http://www.youtube.com/watch?v=O4zsQ1Yh15A" target="_blank">here</a>).</p>
<p>So, ACR, you&#8217;ve been asked to implement the Guidance Document in your MR Accreditation standards. You&#8217;ve said that you would do so. Then you reneged on that promise with an excuse that&#8217;s been shown to be tissue-thin. At the same time, representatives have testified before Congress that <em>in the interest of safety</em>, there should be more accreditation of imaging and therapy devices in more healthcare settings.</p>
<p>Explain to me one more time why it is that you can&#8217;t honor your promise to include MRI safety standards in your MR Accreditation program?</p>
<address><a href="../2011/02/2011/02/2011/01/2010/12/2010/12/2010/12/2010/12/2010/10/about-tobias-gilk-editor/" target="_blank"><strong>Tobias Gilk</strong></a>, </address>
<address> </address>
<address> </address>
<address>President &amp; MRI     Safety Director — Mednovus, Inc.</address>
<address>Tobias.Gilk@Mednovus.com</address>
<address><a title="Click for Mednovus.com" href="http://www.mednovus.com/products.html" target="_blank">www.MEDNOVUS.com</a></address>
<address> </address>
<address> </address>
<address> </address>
<address>Sr. Vice President — RAD-Planning.com</address>
<address>TGilk@RAD-Planning.com</address>
<address><a title="Click For RAD-Planning.com" href="http://www.rad-planning.com/" target="_blank">www.RAD-Planning.com</a><br />
</address>
<address> </address>
<p><a href="http://www.twitter.com/tobiasgilk"><img title="TwitterIcon_32-32" src="../wp-content/uploads/2010/06/TwitterIcon_32-321.gif" alt="Click for Tobias Gilk's Twitter Page" width="32" height="32" /></a><a title="Tobias Gilk on Twitter" href="http://twitter.com/tobiasgilk" target="_blank"> Click here for Tobias’ Twitter Profile</a></p>
<p>PS: Tune back in for the next installment, which will be taking a close look at the Joint Commission&#8217;s role in MRI safety.</p>
]]></content:encoded>
			<wfw:commentRss>http://mrimetaldetector.com/blog/2011/05/mri-safety-per-acr-accreditation-standards/feed/</wfw:commentRss>
		<slash:comments>1</slash:comments>
		</item>
		<item>
		<title>$2.9 Million Settlement Closes Colombini MRI Death Case</title>
		<link>http://mrimetaldetector.com/blog/2010/02/2-9-million-settlement-closes-colombini-mri-death-case/</link>
		<comments>http://mrimetaldetector.com/blog/2010/02/2-9-million-settlement-closes-colombini-mri-death-case/#comments</comments>
		<pubDate>Thu, 04 Feb 2010 10:25:07 +0000</pubDate>
		<dc:creator>Tobias Gilk</dc:creator>
				<category><![CDATA[Ferromagnetic Detection for MRI Safety]]></category>
		<category><![CDATA[Other MRI Safety]]></category>
		<category><![CDATA[accident]]></category>
		<category><![CDATA[civil]]></category>
		<category><![CDATA[colombini]]></category>
		<category><![CDATA[death]]></category>
		<category><![CDATA[fatality]]></category>
		<category><![CDATA[ferromagnetic]]></category>
		<category><![CDATA[hazard]]></category>
		<category><![CDATA[imaging]]></category>
		<category><![CDATA[injury]]></category>
		<category><![CDATA[lawsuit]]></category>
		<category><![CDATA[liability]]></category>
		<category><![CDATA[magnet]]></category>
		<category><![CDATA[magnetic]]></category>
		<category><![CDATA[magnetic resonance]]></category>
		<category><![CDATA[medical]]></category>
		<category><![CDATA[metal]]></category>
		<category><![CDATA[missile]]></category>
		<category><![CDATA[MR]]></category>
		<category><![CDATA[MRI]]></category>
		<category><![CDATA[patient]]></category>
		<category><![CDATA[projectile]]></category>
		<category><![CDATA[radiology]]></category>
		<category><![CDATA[regulation]]></category>
		<category><![CDATA[resonance]]></category>
		<category><![CDATA[safety]]></category>
		<category><![CDATA[screening]]></category>
		<category><![CDATA[suit]]></category>
		<category><![CDATA[trial]]></category>

		<guid isPermaLink="false">http://mrimetaldetector.com/blog/?p=760</guid>
		<description><![CDATA[This week the documents detailing the Michael Colombini MRI-death civil suit ]]></description>
			<content:encoded><![CDATA[<p>This week the settlement documents were released &#8212; closing the chapter on the lawsuit that arose from the seminal event in MRI safety, the 2001 oxygen tank fatality of then-six-year-old Michael Colombini.</p>
<p><span id="more-760"></span>Nearly nine years after the accident, the lawsuit was settled for $2.9 million, a settlement that was likely both diminished by, and made possible by, a pre-trial motion which excused GE Healthcare as a defendant to the suit.</p>
<p>The county-owned hospital, which almost immediately asserted its responsibility for the accident, ultimately settled the case on behalf of all of the remaining defendants, which included the head of radiology and the technologist who administered the boy&#8217;s scan.</p>
<p>Perhaps now, with the lawsuit resolved, we can actually <em><strong>learn</strong></em> something about the events that precipitated this tragedy, beyond the fragmentary slivers of information gleaned from court documents and news accounts.</p>
<p>That&#8217;s right, despite the fact that this one event has become the touchstone for MRI safety, there has not been a single root-cause analysis to inform MRI suite design, departmental operations, regulatory and accreditation frameworks&#8230; at least not one that has been shared with the public.</p>
<p>Hopefully, with the lawsuit resolved and jeopardy attached for all defendants, we can have an open conversation about what contributed to the accident and what can be done, at the thousands of MRI suites across the country, to help see that this sort of accident never recurs. Based on <a title="Click for WSJ Article On Recent Accident" href="http://blogs.wsj.com/health/2010/01/28/yes-metal-things-do-fly-into-mris-and-hurt-people/" target="_blank">recent news accounts</a> and last year&#8217;s <a title="Click for Article On 2009 Projectile Accidents" href="http://mrimetaldetector.com/blog/2009/12/can-we-still-call-them-never-events-when-accidents-happen-so-frequently-in-mri/" target="_blank">shocking collection of ferromagnetic projectile accidents</a>, the lessons from the Colombini tragedy are still profoundly needed.</p>
<p>If we are willing to explore this darkest chapter in the brief history of MRI, we may learn lessons that will help protect the 30 million Americans who will receive MRI&#8217;s this year, and next year, and the year after that.</p>
<p>If we fail, next year we&#8217;ll be able to look back at this moment, wistfully, and imagine young Michael getting his drivers&#8217; license, or attending his junior prom, on the verge of adulthood. But he is forever trapped in 2001&#8230; a victim of circumstances he had no control over.</p>
<p><img class="aligncenter size-full wp-image-761" title="Michael_Colombini" src="http://mrimetaldetector.com/blog/wp-content/uploads/2010/02/Michael_Colombini.jpg" alt="Michael Colombini" width="119" height="130" /></p>
<p>Let&#8217;s see what we can do, together, to help make sure that this never happens again.</p>
<p>My heartfelt thoughts and prayers are extended to the Colombini family.</p>
<address><a href="../2010/01/2010/01/2010/01/2009/12/2009/12/2009/12/2009/12/2009/12/2009/11/2009/11/2009/11/2009/11/2009/11/2009/10/2009/10/2009/10/2009/10/2009/09/2009/09/2009/09/2009/09/2009/09/2009/08/2009/?page_id=314" target="_blank"><strong>Tobias Gilk</strong></a>, President &amp; MRI Safety Director</address>
<address>Mednovus, Inc.</address>
<address>Tobias.Gilk@Mednovus.com</address>
<address> <a title="Click for Mednovus.com" href="http://www.mednovus.com/products.html" target="_blank">www.MEDNOVUS.com</a></address>
<p><a href="../2010/01/gurney-crashes-mri-patient-injured-hospital-fined-50k/www.twitter/com/tobiasgilk"><img title="twittericon_32-32" src="../wp-content/uploads/2009/12/twittericon_32-32.gif" alt="Click for Tobias Gilk's Twitter Profile" width="32" height="32" /></a><a title="Tobias Gilk on Twitter" href="http://twitter.com/tobiasgilk" target="_blank"> Click here for Tobias’ Twitter Profile</a></p>
]]></content:encoded>
			<wfw:commentRss>http://mrimetaldetector.com/blog/2010/02/2-9-million-settlement-closes-colombini-mri-death-case/feed/</wfw:commentRss>
		<slash:comments>3</slash:comments>
		</item>
		<item>
		<title>Gurney Crashes MRI, Patient Injured, Hospital Fined $50K</title>
		<link>http://mrimetaldetector.com/blog/2010/01/gurney-crashes-mri-patient-injured-hospital-fined-50k/</link>
		<comments>http://mrimetaldetector.com/blog/2010/01/gurney-crashes-mri-patient-injured-hospital-fined-50k/#comments</comments>
		<pubDate>Sun, 24 Jan 2010 16:08:45 +0000</pubDate>
		<dc:creator>Tobias Gilk</dc:creator>
				<category><![CDATA[Ferromagnetic Detection for MRI Safety]]></category>
		<category><![CDATA[Other MRI Safety]]></category>
		<category><![CDATA[accident]]></category>
		<category><![CDATA[accreditation]]></category>
		<category><![CDATA[death]]></category>
		<category><![CDATA[detection]]></category>
		<category><![CDATA[detector]]></category>
		<category><![CDATA[FDA]]></category>
		<category><![CDATA[ferromagnetic]]></category>
		<category><![CDATA[hazard]]></category>
		<category><![CDATA[imaging]]></category>
		<category><![CDATA[injury]]></category>
		<category><![CDATA[magnetic]]></category>
		<category><![CDATA[magnetic resonance]]></category>
		<category><![CDATA[MAUDE]]></category>
		<category><![CDATA[medical]]></category>
		<category><![CDATA[metal]]></category>
		<category><![CDATA[missile]]></category>
		<category><![CDATA[MR]]></category>
		<category><![CDATA[MRI]]></category>
		<category><![CDATA[patient]]></category>
		<category><![CDATA[projectile]]></category>
		<category><![CDATA[radiology]]></category>
		<category><![CDATA[regulation]]></category>
		<category><![CDATA[resonance]]></category>
		<category><![CDATA[risk]]></category>
		<category><![CDATA[safety]]></category>
		<category><![CDATA[screening]]></category>
		<category><![CDATA[suit]]></category>

		<guid isPermaLink="false">http://mrimetaldetector.com/blog/?p=739</guid>
		<description><![CDATA[A California hospital got slapped with a $50,000 fine after failing to prevent a patient from being injured by a ferromagnetic gurney (that the patient was riding on) brought into the MRI scanner room.]]></description>
			<content:encoded><![CDATA[<p>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. &#8220;<em>How on Earth could these accidents happen when we </em>know<em> about these risks</em>,&#8221; 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 <strong><em>was</em></strong> until enough pieces fell into place to conclusively document a recent episode&#8230;  <span id="more-739"></span></p>
<p>Many people in the medical industry, even within radiology, are quick to dismiss stories of accidents in the MRI suite as &#8216;fish stories&#8217; which, though they may be based on a kernel of truth from the original telling, grow and grow as the story gets passed along the line. What may have begun as a pager getting drawn into the MRI scanner, winds up becoming a telephone repairman&#8230; or so goes the rationalization.  And some seem to think that most MRI accident stories aren&#8217;t even really exaggerations, but rather pure fiction, akin to what you would see on some nighttime television medical drama. To these people, any account of a patient bed hitting the MRI could only have come from an episode of ER (as opposed to a real accident having become the basis of the TV show&#8217;s fictionalized version)&#8230;</p>
<p style="text-align: center;"></p>
<p>Not that there haven&#8217;t been cases of gurneys drawn to MRI scanners before, because the MRI professional communities are awash in stories of all manners of ferromagnetic materials inadvertently becoming MRI-homing magnet missiles. Everything from personal computers, iPods, pagers, cell phones, anesthesia machines, &#8216;sand&#8217; bags, medical gas (oxygen) cylinders, welding tanks, rolling carts, wheelchairs, hand-tools, canes &amp; walkers, furniture, filing cabinets, hand-trucks, and the list goes on, and on, and on (to see pictures of a number of items, please check out <a title="Click for Post With Lots Of MRI Accident Pictures" href="http://mrimetaldetector.com/blog/2009/05/fmd-dont-we-have-screening-protocols-for-that/" target="_blank">this prior post</a>). And yes, even hospital gurneys&#8230;</p>
<div id="attachment_198" class="wp-caption aligncenter" style="width: 310px"><a href="http://mrimetaldetector.com/blog/wp-content/uploads/2008/11/mri-scanner-eats-patient-bed.jpg"><img class="size-medium wp-image-198" title="mri-scanner-eats-patient-bed" src="http://mrimetaldetector.com/blog/wp-content/uploads/2008/11/mri-scanner-eats-patient-bed-300x225.jpg" alt="" width="300" height="225" /></a><p class="wp-caption-text">MRI Scanner Eats an ICU Patient Bed</p></div>
<p>Much to my chagrin, I&#8217;ve heard people dismiss the above as somebody&#8217;s Photoshop fantasy. Those sorts of statements, sadly, work to diminish all efforts toward MRI safety. But a recent account should, permanently, put to rest any question of whether this sort of thing can really happen.  Late last year I posted a <a title="Click Here For That Story" href="http://mrimetaldetector.com/blog/2009/12/can-we-still-call-them-never-events-when-accidents-happen-so-frequently-in-mri/" target="_blank">story</a> that included links to a number of FDA MRI accident reports. One of the reports to the FDA&#8217;s MAUDE database described an incident in which a patient had their foot-ankle-leg injured when they were transported into the MRI scanner room on a conventional gurney (click <a title="Click to Download FDA Report in PDF Format" href="http://mrimetaldetector.com/media/downloads/MAUDE-Gurney.pdf" target="_blank">here</a> to download the PDF file from the FDA&#8217;s data). The date in the FDA&#8217;s anonymized report coincides very nicely with this somewhat-less-than-anonymous newspaper article that just came out&#8230;</p>
<p style="padding-left: 30px;"><em>Hoag Hospital has been fined $50,000 by the state Department of Public Health after an MRI patient on a metal gurney was magnetically pulled into the imaging machine, the hospital said Friday.</em></p>
<p style="padding-left: 30px;"><em> [Dr. Richard] Afable, [chief executive officer of Hoag Memorial Hospital Presbyterian], said that last January a woman was taken into an MRI room on a metal gurney that was not compatible with the machine. The powerful magnet in the MRI pulled the gurney into the machine and the patient&#8217;s leg was trapped for about three minutes. She was taken to the emergency room and spent three days in the hospital for treatment of fractures in her lower leg and foot.</em></p>
<p>The above quote is taken from the January 22nd, 2009 article appearing on the Orange County Register&#8217;s website (click <a title="Click Here For That Story" href="http://www.ocregister.com/articles/mri-230615-hospital-hoag.html" target="_blank">here</a> to go straight to the article).  Based on the dates, the description of the accident, and the patient injuries, it sounds as if the FDA account <em><strong>is the same incident</strong></em> as what is described in this newspaper article.  The $50,000 fine may sound like steep punishment, but considering the cost to restore the magnet after the quench (described in the FDA account), the cost of downtime and lost revenue between the accident and the time the MRI was returned to service, the cost of care to treat the patient, the cost of internal safety / quality / regulatory investigations, the legal costs for the hospital, and any lawsuit settlement costs, the state&#8217;s penalty is likely to just be icing on the cake. The cost to the hospital for this transgression could very easily be into 7-figures!  All of this simply demonstrates two critical points about MRI safety.</p>
<ol>
<li>MRI accidents do happen, and at greater frequency and cost than many are led to believe.</li>
<li>The costs of the safety provisions to help prevent these accidents are peanuts when compared to the costs of accidents.</li>
</ol>
<p>My soap-box pontificating on this point will likely become moot over the next many months. In a &#8216;perfect storm&#8217; of regulatory and accreditation attention to MRI safety, we&#8217;re very likely to see <strong>requirements</strong> for MRI safety provisions, such as ferromagnetic detectors (which could have been instrumental in helping to avoid this gurney accident). I will share more about each of these efforts, as I&#8217;m able.  In the meantime, MRI providers should put a great deal more stock in the validity of MRI accidents accounts and ask themselves, &#8220;Do I have adequate physical protections in place, beyond what&#8217;s written in my policy manual, to help prevent this sort of accident?&#8221; The likely answer is &#8220;No.&#8221;</p>
<address><a href="../2010/01/2010/01/2009/12/2009/12/2009/12/2009/12/2009/12/2009/11/2009/11/2009/11/2009/11/2009/11/2009/10/2009/10/2009/10/2009/10/2009/09/2009/09/2009/09/2009/09/2009/09/2009/08/2009/?page_id=314" target="_blank"><strong>Tobias Gilk</strong></a>, President &amp; MRI Safety Director</address>
<address>Mednovus, Inc.</address>
<address>Tobias.Gilk@Mednovus.com</address>
<address> <a title="Click for Mednovus.com" href="http://www.mednovus.com/products.html" target="_blank">www.MEDNOVUS.com</a></address>
<p><a href="www.twitter/com/tobiasgilk"><img class="size-full wp-image-721 alignnone" title="twittericon_32-32" src="http://mrimetaldetector.com/blog/wp-content/uploads/2009/12/twittericon_32-32.gif" alt="Click for Tobias Gilk's Twitter Profile" width="32" height="32" /></a><a title="Tobias Gilk on Twitter" href="http://twitter.com/tobiasgilk" target="_blank"> Click here for Tobias’ Twitter Profile</a></p>
]]></content:encoded>
			<wfw:commentRss>http://mrimetaldetector.com/blog/2010/01/gurney-crashes-mri-patient-injured-hospital-fined-50k/feed/</wfw:commentRss>
		<slash:comments>4</slash:comments>
	<!-- Media File exists for this post, but its not enabled for this feed -->
	</item>
		<item>
		<title>2010 &#8216;Guidelines&#8217; Healthcare Building Code To Have MRI Safety Requirements</title>
		<link>http://mrimetaldetector.com/blog/2009/11/2010-guidelines-code-mri-safety-requirements/</link>
		<comments>http://mrimetaldetector.com/blog/2009/11/2010-guidelines-code-mri-safety-requirements/#comments</comments>
		<pubDate>Tue, 17 Nov 2009 20:43:07 +0000</pubDate>
		<dc:creator>Tobias Gilk</dc:creator>
				<category><![CDATA[Ferromagnetic Detection for MRI Safety]]></category>
		<category><![CDATA[Other MRI Safety]]></category>
		<category><![CDATA[accreditation]]></category>
		<category><![CDATA[ACR]]></category>
		<category><![CDATA[architecture]]></category>
		<category><![CDATA[building code]]></category>
		<category><![CDATA[design]]></category>
		<category><![CDATA[detection]]></category>
		<category><![CDATA[detector]]></category>
		<category><![CDATA[Environment of Care]]></category>
		<category><![CDATA[ferromagnetic]]></category>
		<category><![CDATA[guidelines]]></category>
		<category><![CDATA[hazard]]></category>
		<category><![CDATA[imaging]]></category>
		<category><![CDATA[JCAHO]]></category>
		<category><![CDATA[Joint Commission]]></category>
		<category><![CDATA[metal]]></category>
		<category><![CDATA[MR]]></category>
		<category><![CDATA[MRI]]></category>
		<category><![CDATA[radiology]]></category>
		<category><![CDATA[regulation]]></category>
		<category><![CDATA[resonance]]></category>
		<category><![CDATA[risk]]></category>
		<category><![CDATA[safety]]></category>
		<category><![CDATA[standard]]></category>
		<category><![CDATA[standard of care]]></category>
		<category><![CDATA[suite]]></category>

		<guid isPermaLink="false">http://mrimetaldetector.com/blog/?p=641</guid>
		<description><![CDATA[Have doubts about the necessity of safety elements in the design of MRI facilities? The forthcoming 2010 edition of Guidelines will put those to rest.]]></description>
			<content:encoded><![CDATA[<p>&#8220;Tweet, tweet&#8221; is usually all I hear from little birdies&#8230; but one little bird that flew past my office recently had a surprisingly large vocabulary and told me of new requirements that will be introduced in the forthcoming 2010 update to the &#8216;Guidelines for Design and Construction of Health Care Facilities&#8217; (commonly referred to as &#8216;Guidelines&#8217;).</p>
<p>For those of you who aren&#8217;t familiar with the Guidelines, they are the design requirements that are cited by the Joint Commission and, at last count, 42 of the 50 U.S. State Departments of Health. Technically, they aren&#8217;t a building <em>code</em>, but the function in almost the exact same way. For the first time, the Guidelines are going to have specific MRI suite design requirements for patient safety.</p>
<div id="attachment_642" class="wp-caption aligncenter" style="width: 233px"><a href="http://fgiguidelines.org/"><img class="size-full wp-image-642 " title="fgi-guidelines-book-cover" src="http://mrimetaldetector.com/blog/wp-content/uploads/2009/11/fgi-guidelines-book-cover.jpg" alt="2010 Guidelines" width="223" height="269" /></a><p class="wp-caption-text">2010 Guidelines</p></div>
<p><span id="more-641"></span>The 2010 edition of the Guidelines are purported to codify the single most often cited MRI suite safety design criteria, the 5-gauss line (or three-dimensional bubble, more accurately). The design must necessarily control access to locations where the static magnetic field is present at strengths of 5-gauss or more.</p>
<p>the 2010 Guidelines will also define situational-awareness requirements for suite layouts. These will include a requirement that the patient can be seen inside the scanner from the operators&#8217; console location, and that the operator has direct visual control of the entrance to the MR scanner room.</p>
<p>The unique challenges of infection control and handwashing in the MRI environment are also explicitly addressed, for the first time, in the new Guidelines.</p>
<p>And one of my favorite provisions is the new requirement that MRI suites be designed to follow the ACR 4-Zone model for screening and access controls, <strong>including ferromagnetic detection systems</strong>!</p>
<p>The Guidelines publication is undergoing a significant organizational overhaul along with the regular content update, so I don&#8217;t have specific section citations to where the new MRI safety design requirements will be (though MRI probably won&#8217;t have the same section numbers as the current, 2006, edition has). My understanding, however, is that the publication will be released on schedule in January, so it is only a very short time until we can verify the specific contents and section numbers.</p>
<p>It is particularly encouraging that these new requirements validate what the some of the best MRI providers have been doing for years. Clearly MRI site-safety, including ferromagnetic detection, can no longer be regarded as simply &#8220;a good idea.&#8221; With the 2010 edition of Guidelines, we will have one more codified example of how these elements are truly part of the contemporary standard of care.</p>
<p>If you would like more information about the Guidelines, including information on how to order a copy of the document, please click <a title="Click for Guidelines' website" href="http://fgiguidelines.org/" target="_blank">here</a>.</p>
<address><a href="../2009/10/2009/10/2009/10/2009/10/2009/09/2009/09/2009/09/2009/09/2009/09/2009/08/2009/?page_id=314" target="_blank"><strong>Tobias Gilk</strong></a>, President &amp; MRI Safety Director</address>
<address>Mednovus, Inc.</address>
<address>Tobias.Gilk@Mednovus.com</address>
<address> <a title="Link to MEDNOVUS.com" href="http://www.mednovus.com/" target="_blank">www.MEDNOVUS.com</a></address>
<address><a title="View Tobias' Twitter Page" href="http://twitter.com/tobiasgilk"><img class="alignnone size-full wp-image-575" title="twittericon_32-32" src="http://mrimetaldetector.com/blog/wp-content/uploads/2009/02/twittericon_32-32.gif" alt="twittericon_32-32" /></a><a title="View Tobias' Twitter Page" href="http://twitter.com/tobiasgilk" target="_blank">Link</a></p>
</address>
]]></content:encoded>
			<wfw:commentRss>http://mrimetaldetector.com/blog/2009/11/2010-guidelines-code-mri-safety-requirements/feed/</wfw:commentRss>
		<slash:comments>0</slash:comments>
		</item>
		<item>
		<title>RT-Image&#8217;s August 3 Issue on MRI Safety</title>
		<link>http://mrimetaldetector.com/blog/2009/08/rt-images-august-3-issue-on-mri-safety/</link>
		<comments>http://mrimetaldetector.com/blog/2009/08/rt-images-august-3-issue-on-mri-safety/#comments</comments>
		<pubDate>Wed, 19 Aug 2009 18:58:54 +0000</pubDate>
		<dc:creator>Tobias Gilk</dc:creator>
				<category><![CDATA[Ferromagnetic Detection for MRI Safety]]></category>
		<category><![CDATA[Other MRI Safety]]></category>
		<category><![CDATA[accident]]></category>
		<category><![CDATA[AHRA]]></category>
		<category><![CDATA[article]]></category>
		<category><![CDATA[hazard]]></category>
		<category><![CDATA[imaging]]></category>
		<category><![CDATA[injury]]></category>
		<category><![CDATA[liability]]></category>
		<category><![CDATA[magnetic]]></category>
		<category><![CDATA[magnetic resonance]]></category>
		<category><![CDATA[MAUDE]]></category>
		<category><![CDATA[MR]]></category>
		<category><![CDATA[MRI]]></category>
		<category><![CDATA[patient]]></category>
		<category><![CDATA[radiology]]></category>
		<category><![CDATA[risk]]></category>
		<category><![CDATA[RT-Image]]></category>
		<category><![CDATA[safety]]></category>

		<guid isPermaLink="false">http://mrimetaldetector.com/blog/?p=553</guid>
		<description><![CDATA[RT-Image publishes article by Tobias Gilk on increasing MRI accident rate.]]></description>
			<content:encoded><![CDATA[<p>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&#8230;</p>
<p><span id="more-553"></span>If you&#8217;d like to read the article, &#8220;Risky Business: MRI accidents increase fourfold in as many years,&#8221; pick up your copy of RT-Image that looks like this (below):</p>
<div class="wp-caption aligncenter" style="width: 210px"><a href="http://www.rt-image.com/Risky_Business_MRI_accidents_increase_fourfold_in_as_many_years/content=8804J05E48B6A68640B698724488A0441"><img title="RT-Image Aug. 3, 2009 Cover" src="http://www.rt-image.com/uploads/images/Cover080309.jpg" alt="RT-Image | August 3, 2009" width="200" height="259" /></a><p class="wp-caption-text">RT-Image | August 3, 2009</p></div>
<p>Or you can simply click on the cover image (above) or <a title="Link to RT-Image article" href="http://www.rt-image.com/Risky_Business_MRI_accidents_increase_fourfold_in_as_many_years/content=8804J05E48B6A68640B698724488A0441" target="_blank">right here</a> to be taken to the online version of the article.</p>
<p>Thank you for your ongoing attention to improving MRI safety!</p>
<address><a href="../../?page_id=314" target="_blank"><strong>Tobias Gilk</strong></a>, President &amp; MRI Safety Director</address>
<address>Mednovus, Inc.</address>
<address>Tobias.Gilk@Mednovus.com</address>
<address> <a title="Link to MEDNOVUS.com" href="http://www.mednovus.com/" target="_blank">www.MEDNOVUS.com</a></address>
]]></content:encoded>
			<wfw:commentRss>http://mrimetaldetector.com/blog/2009/08/rt-images-august-3-issue-on-mri-safety/feed/</wfw:commentRss>
		<slash:comments>0</slash:comments>
		</item>
		<item>
		<title>MRI Safety Week &#8211; Free Training Downloads</title>
		<link>http://mrimetaldetector.com/blog/2009/07/mri-safety-week-free-training-downloads/</link>
		<comments>http://mrimetaldetector.com/blog/2009/07/mri-safety-week-free-training-downloads/#comments</comments>
		<pubDate>Mon, 06 Jul 2009 17:08:53 +0000</pubDate>
		<dc:creator>Tobias Gilk</dc:creator>
				<category><![CDATA[Other MRI Safety]]></category>
		<category><![CDATA[accident]]></category>
		<category><![CDATA[death]]></category>
		<category><![CDATA[imaging]]></category>
		<category><![CDATA[injury]]></category>
		<category><![CDATA[magnet]]></category>
		<category><![CDATA[magnetic resonance]]></category>
		<category><![CDATA[Mednovus]]></category>
		<category><![CDATA[MR]]></category>
		<category><![CDATA[MRI]]></category>
		<category><![CDATA[radiology]]></category>
		<category><![CDATA[SAFESCAN]]></category>
		<category><![CDATA[safety]]></category>
		<category><![CDATA[screening]]></category>
		<category><![CDATA[suit]]></category>
		<category><![CDATA[Technologist]]></category>

		<guid isPermaLink="false">http://mrimetaldetector.com/blog/?p=531</guid>
		<description><![CDATA[MRI Safety Week comes only once per year. This year, thanks to Mednovus, makers of the SAFESCAN® MRI screening products, we have a number informative and entertaining resources for you.]]></description>
			<content:encoded><![CDATA[<p>Once again, we&#8217;re approaching the anniversary date of the most infamous MRI fatality and the corresponding MRI Safety Week. This year, through the in-kind support of my employer, Mednovus, I&#8217;m able to make available a MRI safety quiz (actually, it&#8217;s two quizzes, one for radiology / MR staff and one for the MRI layperson).</p>
<p><span id="more-531"></span>Eight years ago this month (July 27th, 2001, to be exact), young Michael Colombini was fatally injured in an MRI accident involving a portable oxygen cylinder. The week surrounding the date of that accident is set aside each year as MRI Safety Week. This year, 2009, it falls July 27th through August 2nd.</p>
<p>During MRI Safety Week, MRI providers are encouraged to provide additional emphasis on safety provisions, training, inspection and equipment. This could serve as the anniversary date for annual inspections (cryogen safety systems, infection control, etc&#8230;). It is sometimes the additional motivator for special projects like labeling all portable equipment with the contemporary MR Safe, MR Conditional, MR Unsafe labels and designations. And sometimes it can be an opportunity to reinforce safety training for our MR staff and share a little bit of our daily safety mission with those outside MRI.</p>
<p>To make this easier, I&#8217;m posting two free Jeopardy-styled MRI safety quizzes (in Power Point format) for you to use for your staff, or for those who may not be quite so familiar with MRI safety. These resources are available at my new <a title="MRI Safety Week" href="http://mrimetaldetector.com/media/proving_grounds/MRI_safety_week.html" target="_blank">MRI Safety Week webpage</a>.</p>
<p>But beyond sharing these resources with you, I am also offering for this to serve as a clearinghouse of MRI safety resources that you want to share with your colleagues. Drop me an email (my contact information is always at the foot of each post, or in the &#8216;about Tobias Gilk, editor&#8217; in the box above and to the right) and we&#8217;ll see if we can share your posters, table-tents, questionnaires, articles, quizzes, or other downloadable resource with the broader MRI community.</p>
<p>This year, MRI Safety Week is more important than ever. The number of MRI exams continues to slowly climb, year-over-year, but rates of reported accidents are skyrocketing! We&#8217;ve seen nearly a 3-fold increase in the number of MRI accident reports to the FDA in just the last 4 years. Collectively, we have the opportunity to make a substantial impact in MRI safety.</p>
<p>Thanks to Mednovus for allowing me the time and resources to prepare these materials for you. But mostly, thank you for joining with me in again celebrating and promoting excellence in MRI safety through this special week.</p>
<address><a href="../../?page_id=314" target="_blank"><strong>Tobias Gilk</strong></a>, President &amp; MRI Safety Director</address>
<address>Mednovus, Inc.</address>
<address>Tobias.Gilk@Mednovus.com</address>
<address> <a title="Link to MEDNOVUS.com" href="http://www.mednovus.com/" target="_blank">www.MEDNOVUS.com</a></address>
]]></content:encoded>
			<wfw:commentRss>http://mrimetaldetector.com/blog/2009/07/mri-safety-week-free-training-downloads/feed/</wfw:commentRss>
		<slash:comments>2</slash:comments>
		</item>
		<item>
		<title>FMD. Don&#8217;t We Have Screening Protocols For That?</title>
		<link>http://mrimetaldetector.com/blog/2009/05/fmd-dont-we-have-screening-protocols-for-that/</link>
		<comments>http://mrimetaldetector.com/blog/2009/05/fmd-dont-we-have-screening-protocols-for-that/#comments</comments>
		<pubDate>Fri, 22 May 2009 22:17:26 +0000</pubDate>
		<dc:creator>Tobias Gilk</dc:creator>
				<category><![CDATA[Ferromagnetic Detection for MRI Safety]]></category>
		<category><![CDATA[accident]]></category>
		<category><![CDATA[care]]></category>
		<category><![CDATA[detection]]></category>
		<category><![CDATA[detector]]></category>
		<category><![CDATA[fatality]]></category>
		<category><![CDATA[ferromagnetic]]></category>
		<category><![CDATA[hazard]]></category>
		<category><![CDATA[injury]]></category>
		<category><![CDATA[magnet]]></category>
		<category><![CDATA[magnetic resonance]]></category>
		<category><![CDATA[metal]]></category>
		<category><![CDATA[missile]]></category>
		<category><![CDATA[MR]]></category>
		<category><![CDATA[MRI]]></category>
		<category><![CDATA[patient]]></category>
		<category><![CDATA[photo]]></category>
		<category><![CDATA[picture]]></category>
		<category><![CDATA[projectile]]></category>
		<category><![CDATA[risk]]></category>
		<category><![CDATA[safety]]></category>
		<category><![CDATA[screening]]></category>
		<category><![CDATA[standard]]></category>
		<category><![CDATA[Technologist]]></category>
		<category><![CDATA[translational]]></category>
		<category><![CDATA[video]]></category>

		<guid isPermaLink="false">http://mrimetaldetector.com/blog/?p=482</guid>
		<description><![CDATA[Is ferromagnetic detection redundant when we have technologists to screen patients and visitors? Our photographic documentation suggests that we need ferromagnetic detection to protect patients, staff and our MRI's...]]></description>
			<content:encoded><![CDATA[<p>One of the most oft-cited rationalizations for not complying with contemporary best practices that call for using ferromagnetic detection (FMD) for MRI pre-screening is that &#8216;FMD doesn&#8217;t catch anything that existing screening protocols aren&#8217;t meant to catch.&#8217; What you may find surprising about this statement is that I agree with it wholeheartedly&#8230; I would just change the inflection a bit. I would say it more like&#8230;</p>
<p style="padding-left: 30px;">Ferromagnetic detection doesn&#8217;t catch anything that existing screening protocols aren&#8217;t <span style="text-decoration: underline;"><em>meant</em></span> to catch.<em> </em></p>
<p>That inflection makes a world of difference, as you&#8217;ll see in just a moment&#8230;</p>
<p><span id="more-482"></span>We&#8217;ve been screening for ferromagnetic materials as long as MRI has existed, but our historic technique of simply asking if someone has magnetic materials has not proven very effective. There are many accounts of magnet damage, injuries, and fatalities resulting from a failure to identify ferromagnetic materials before they were brought into the MRI room. And despite a universal familiarity with the risks of ferromagnetic materials, we as an industry seem unable to prevent them from recurring by using only these &#8216;old school&#8217; screening protocols.</p>
<p>There was a policy in place to screen for ferromagnetic materials at this New York hospital in 2001:</p>
<p><a rel="attachment wp-att-483" href="http://mrimetaldetector.com/blog/?attachment_id=483"><img class="aligncenter size-full wp-image-483" title="Colombini Accident Newspaper Clippings" src="http://mrimetaldetector.com/blog/wp-content/uploads/2009/05/newspaper-3.jpg" alt="Steel Oxygen Cylinder Kills Boy" /></a></p>
<p>And they had a policy to screen for ferromagnetic materials at this <a title="Click to read about this accident." href="http://www.seattlepi.com/local/207390_mri11.html" target="_blank">Seattle hospital in 2005</a>:</p>
<p>They had a policy to screen for ferromagnetic materials at this hospital:</p>
<h3 style="text-align: center;"></h3>
<p>And here:</p>
<p style="text-align: left;"><img class="aligncenter size-full wp-image-198" title="mri-scanner-eats-patient-bed" src="http://mrimetaldetector.com/blog/wp-content/uploads/2008/11/mri-scanner-eats-patient-bed.jpg" alt="MRI Scanner Eats an ICU Patient Bed" width="426" height="320" /></p>
<p style="text-align: left;">And here:</p>
<p style="text-align: center;"><img class="aligncenter size-full wp-image-485" title="floor-buffer" src="http://mrimetaldetector.com/blog/wp-content/uploads/2009/05/floor-buffer.jpg" alt="MRI Eats Floor Buffer" width="368" height="277" /></p>
<p>And here:</p>
<p style="text-align: left;"><img class="aligncenter size-full wp-image-486" title="floor-buffer-fs" src="http://mrimetaldetector.com/blog/wp-content/uploads/2009/05/floor-buffer-fs.jpg" alt="MRI vs. Floor Buffer... MRI Wins!" width="336" height="252" /></p>
<p style="text-align: left;">And here:</p>
<p style="text-align: center;"><img class="aligncenter size-full wp-image-487" title="wheelchair_in_bore" src="http://mrimetaldetector.com/blog/wp-content/uploads/2009/05/wheelchair_in_bore.jpg" alt="MRI Eats A Wheelchair" width="386" height="290" /></p>
<p style="text-align: left;">And here:</p>
<p style="text-align: center;"><img class="aligncenter size-full wp-image-488" title="weldtank-in-bore" src="http://mrimetaldetector.com/blog/wp-content/uploads/2009/05/weldtank-in-bore.jpg" alt="Welding Torch Gas Cylinder In MRI" width="353" height="214" /></p>
<p style="text-align: left;">And here:</p>
<p style="text-align: left;"><img class="aligncenter size-full wp-image-489" title="o2-tank-in-bore-3" src="http://mrimetaldetector.com/blog/wp-content/uploads/2009/05/o2-tank-in-bore-3.gif" alt="Oxygen Cylinder / Tank In MRI" /></p>
<p style="text-align: left;">And here:</p>
<p style="text-align: left;"><img class="aligncenter size-full wp-image-499" title="02tank1" src="http://mrimetaldetector.com/blog/wp-content/uploads/2009/05/02tank1.jpg" alt="Another Oxygen Tank Inside an MRI" /></p>
<p style="text-align: left;">And here:</p>
<p style="text-align: center;"><img class="aligncenter size-full wp-image-502" title="chair" src="http://mrimetaldetector.com/blog/wp-content/uploads/2009/05/chair.jpg" alt="Another Chair In An MRI" width="342" height="331" /></p>
<p style="text-align: left;">And here:</p>
<p style="text-align: center;"><img class="aligncenter size-full wp-image-503" title="basketchair" src="http://mrimetaldetector.com/blog/wp-content/uploads/2009/05/basketchair.jpg" alt="Basket Chair In MRI" width="344" height="258" /></p>
<p style="text-align: left;">And here:</p>
<p style="text-align: left;"><img class="aligncenter size-full wp-image-504" title="cleaner1" src="http://mrimetaldetector.com/blog/wp-content/uploads/2009/05/cleaner1.jpg" alt="Floor Cleaner Stuck To MRI" /></p>
<p style="text-align: left;">And here:</p>
<p style="text-align: center;"><img class="aligncenter size-full wp-image-505" title="mriscrubber" src="http://mrimetaldetector.com/blog/wp-content/uploads/2009/05/mriscrubber.jpg" alt="Floor Buffer In MRI" width="336" height="296" /></p>
<p style="text-align: left;">And here:</p>
<p style="text-align: left;"><img class="aligncenter size-full wp-image-507" title="oxy7_72dpi" src="http://mrimetaldetector.com/blog/wp-content/uploads/2009/05/oxy7_72dpi.jpg" alt="Removing Oxygen Cylinder From MRI" /></p>
<p style="text-align: left;">And here:</p>
<p style="text-align: center;"><img class="aligncenter size-full wp-image-508" title="anesthesia_vent_on_mri" src="http://mrimetaldetector.com/blog/wp-content/uploads/2009/05/anesthesia_vent_on_mri.jpg" alt="Anesthesia Vent on MRI" width="362" height="272" /></p>
<p style="text-align: left;">And here:</p>
<p style="text-align: center;"><img class="aligncenter size-full wp-image-509" title="kdg_hand-truck_on_mri" src="http://mrimetaldetector.com/blog/wp-content/uploads/2009/05/kdg_hand-truck_on_mri.jpg" alt="Dolly On MRI" width="290" height="362" /></p>
<p style="text-align: left;">And <a title="Peer-reviewed article on medical gas cylinder accidents." href="http://www.ajronline.org/cgi/content/full/177/1/27" target="_blank">here</a>:</p>
<p style="text-align: left;">And <a title="Pistol brought into MRI room." href="http://www.ajronline.org/cgi/content/full/178/5/1092" target="_blank">here</a>:</p>
<p style="text-align: left;">And lots, and lots of places that you can see <a title="Simply Physics" href="http://www.simplyphysics.com/flying_objects.html" target="_blank">here</a>:</p>
<p style="text-align: left;">Honestly, I could drown you in pictures and accounts of ferromagnetic materials in the MRI suite. Suffice it to say that the accounts above are only the tip of the iceberg.</p>
<p style="text-align: left;">One of the most ironic (in light of what you&#8217;ve seen above) arguments against the need for ferromagnetic detection is that it isn&#8217;t foolproof.</p>
<p style="text-align: left;">Foolproof!?!? If that&#8217;s the standard, how can we reconcile the results of our conventional screening practices against this expectation of perfection? Clearly, we&#8217;re a very, very long way from that goal.</p>
<p style="text-align: left;">Instead of willfully disbelieving everything shown above&#8230; Instead of insisting on the infallibility of patient and visitor compliance with screening instructions, or the unblinking door-watching vigilance of the Technologists, or the guaranteed long-term effectiveness of MRI safety training for housekeeping, transport, engineering, security, anesthesia, ICU and respiratory staff, why can&#8217;t we accept that each of these protections, as valuable as they are, are imperfect, and that if maximum safety is our goal, we need to augment these long-standing &#8211; and incomplete &#8211; strategies with something new.</p>
<p style="text-align: left;">I freely state that ferromagnetic detection is not perfect. Under certain circumstances, it can miss things that we may want to find. It does, however, provide us with an entirely new feedback mechanism that helps us to more effectively monitor, train, screen, and protect people in the MRI environment. Imperfect though it is, it is remarkably effective at helping to improve the safety of everyone inside the MRI suite.</p>
<address><a href="../../?page_id=314" target="_blank"><strong>Tobias Gilk</strong></a>, President &amp; MRI Safety Director</address>
<address>Mednovus, Inc.</address>
<address>Tobias.Gilk@Mednovus.com</address>
<address> <a title="Link to MEDNOVUS.com" href="http://www.mednovus.com/" target="_blank">www.MEDNOVUS.com</a></address>
<p>PS: I would like to thank the following people who have helped me by providing some of the images you&#8217;ve seen above, <a href="http://www.simplyphysics.com/flying_objects.html" target="_blank">Moriel Ness Aiver</a>, Raj Sangoi, and <a href="http://www.facebook.com/group.php?gid=119488190267" target="_blank">Keith Del Guercio</a>.</p>
]]></content:encoded>
			<wfw:commentRss>http://mrimetaldetector.com/blog/2009/05/fmd-dont-we-have-screening-protocols-for-that/feed/</wfw:commentRss>
		<slash:comments>4</slash:comments>
			<enclosure url="http://www.youtube.com/watch?v=4uzJPpC4Wuk" length="1" type="application/unknown" />
		<itunes:duration>0:00:01</itunes:duration>
		<itunes:subtitle>Is ferromagnetic detection redundant when we have technologists to screen patients and visitors? Our photographic documentation suggests that we need ferromagnetic detection to protect patients, staff and our MRI's...</itunes:subtitle>
		<itunes:summary>Is ferromagnetic detection redundant when we have technologists to screen patients and visitors? Our photographic documentation suggests that we need ferromagnetic detection to protect patients, staff and our MRI's...</itunes:summary>
		<itunes:author>tobias.gilk@mednovus.com</itunes:author>
		<itunes:explicit>no</itunes:explicit>
		<itunes:block>no</itunes:block>
	</item>
		<item>
		<title>JCAHO and MRI Safety&#8230; Are They Serious?</title>
		<link>http://mrimetaldetector.com/blog/2009/01/jcaho-and-mri-safety-are-they-serious/</link>
		<comments>http://mrimetaldetector.com/blog/2009/01/jcaho-and-mri-safety-are-they-serious/#comments</comments>
		<pubDate>Thu, 01 Jan 2009 15:35:53 +0000</pubDate>
		<dc:creator>Tobias Gilk</dc:creator>
				<category><![CDATA[Ferromagnetic Detection for MRI Safety]]></category>
		<category><![CDATA[Other MRI Safety]]></category>
		<category><![CDATA[accident]]></category>
		<category><![CDATA[accredit]]></category>
		<category><![CDATA[accreditation]]></category>
		<category><![CDATA[EC]]></category>
		<category><![CDATA[Environment of Care]]></category>
		<category><![CDATA[JCAHO]]></category>
		<category><![CDATA[Joint Commission]]></category>
		<category><![CDATA[MR]]></category>
		<category><![CDATA[MRI]]></category>
		<category><![CDATA[patient]]></category>
		<category><![CDATA[safety]]></category>
		<category><![CDATA[SEA]]></category>
		<category><![CDATA[Sentinel Event Alert]]></category>
		<category><![CDATA[standard]]></category>

		<guid isPermaLink="false">http://mrimetaldetector.com/blog/?p=265</guid>
		<description><![CDATA[Will the new MRI safety component of the Joint Commission (JCAHO) Environment of Care (EC) mean more than a check-box for a non-magnetic fire extinguisher? Are they serious about MRI safety?]]></description>
			<content:encoded><![CDATA[<p>As you may be aware, the Joint Commission has historically offered nothing in the way of MRI-specific safety standards. MRI may be the only service at an accredited provider that had not even one specific JCAHO standard for patient safety. Yes, all of the broader patient safety standards apply to MRI as they do to the rest of the provider, but with so many unique risks, wouldn&#8217;t you think that they would have at least <em>one</em> MRI-specific safety standard?</p>
<p><span id="more-265"></span>This isn&#8217;t to say that surveyors haven&#8217;t made their way to MRI, either shadowing a patient or as an intended visit to simply see the department. And this isn&#8217;t to say that the surveyors haven&#8217;t reviewed and commented upon MRI safety issues in the suite. What I <em>do</em> intend to say is that without a substantive backing of codified standards, Joint Commission surveyors &#8216;from the hip&#8217; comments on MRI safety will be irregular and not very effective. But has all of this been changed &#8211; today, January 1st, 2009 &#8211; for accredited MRI providers?</p>
<p>That&#8217;s right, today the 2008 revisions to the Joint Commission&#8217;s Environment of Care (EC) standard are in effect. And while the JC has not been promulgating new MRI-specific standards, a major change just slipped in through the back door.</p>
<p>The new EC standard requires that accredited providers perform risk analyses using, as a minimum standard, all previously released Sentinel Event Alerts (42 as of this writing). One of these is the MRI Sentinel Event Alert (#38) which details a number of MRI safety objectives.</p>
<p>Once the risk analysis is completed for MRI, a corrective plan must be developed (complete with concrete objectives and a time line for implementation) and each incremental step documented.</p>
<p>This, at least, is how the new EC standard <em>reads</em> on MRI safety. Whether the Joint Commission surveyors will be taking the safety criteria of their own Sentinel Event Alert seriously should be revealed in the next few weeks as the first surveys of 2009 are completed.</p>
<p>While not every MRI provider is Joint Commission accredited, there&#8217;s no denying JCAHO&#8217;s influence in the broader industry. The Joint Commission now has the opportunity to not only to promote MRI safety at their accredited providers, but to the entire MRI community.</p>
<p>They have the criteria (SEA #38), they have the accreditation standard (Environment of Care), now the only question is &#8216;are they serious about MRI safety?&#8217;</p>
<address><strong>Tobias Gilk</strong>, President &amp; MRI Safety Director</address>
<address>Mednovus, Inc.</address>
<address>Tobias.Gilk@Mednovus.com</address>
<address> <a title="Link to MEDNOVUS.com" href="http://www.mednovus.com/" target="_blank">www.MEDNOVUS.com</a></address>
]]></content:encoded>
			<wfw:commentRss>http://mrimetaldetector.com/blog/2009/01/jcaho-and-mri-safety-are-they-serious/feed/</wfw:commentRss>
		<slash:comments>0</slash:comments>
		</item>
		<item>
		<title>&#8216;No More&#8217; In &#8217;09</title>
		<link>http://mrimetaldetector.com/blog/2008/12/no-more-in-09/</link>
		<comments>http://mrimetaldetector.com/blog/2008/12/no-more-in-09/#comments</comments>
		<pubDate>Wed, 31 Dec 2008 15:09:37 +0000</pubDate>
		<dc:creator>Tobias Gilk</dc:creator>
				<category><![CDATA[Ferromagnetic Detection for MRI Safety]]></category>
		<category><![CDATA[Other MRI Safety]]></category>
		<category><![CDATA[accident]]></category>
		<category><![CDATA[injury]]></category>
		<category><![CDATA[magnetic]]></category>
		<category><![CDATA[management]]></category>
		<category><![CDATA[MR]]></category>
		<category><![CDATA[MRI]]></category>
		<category><![CDATA[never event]]></category>
		<category><![CDATA[resolution]]></category>
		<category><![CDATA[resonance]]></category>
		<category><![CDATA[risk]]></category>
		<category><![CDATA[safety]]></category>
		<category><![CDATA[Technologist]]></category>

		<guid isPermaLink="false">http://mrimetaldetector.com/blog/?p=261</guid>
		<description><![CDATA[Before we can reduce MRI accidents, we first need to stop the out-of-control growth of MRI accidents. Join the 'No More' in '09 pledge to improve safety by holding the tally of these 'never events' to the 2008 level.]]></description>
			<content:encoded><![CDATA[<p>With around 8,000 &#8211; 10,000 MRI&#8217;s in the US alone, I&#8217;m not naive enough to think that we can wholly reshape behavior in all, or even a majority, of MRI providers in a single year. I do believe, however, that we can set a realistic goal to improve MRI safety.</p>
<p><span id="more-261"></span>It starts with the evidence that nearly all FDA reported MRI accidents fall into the &#8216;never event&#8217; categories of projectiles, burns and hearing damage. These accidents aren&#8217;t complicated. They don&#8217;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&#8217;t, or because something that shouldn&#8217;t be there (ferromagnetic objects) is.</p>
<p>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&#8217;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&#8217;s pre-flight run-down.</p>
<ol>
<li>Did Mrs. Jones pass the clinical-contraindication screening?</li>
<li>Are there contraindications for contrast?</li>
<li>Did she effectively change / gown / remove metal?</li>
<li>Did she the clear the ferromagnetic detector without it alarming?</li>
<li>Was the intercom explained to her?</li>
<li>Was the squeeze ball explained to her?</li>
<li>Was she given the squeeze ball?</li>
<li>Was she positioned / padded so that she doesn&#8217;t contact the bore wall?</li>
<li>Was she positioned / padded so that her body doesn&#8217;t form any large-caliber loops?</li>
<li>Was she instructed about maintaining body position throughout the exam?</li>
<li>Was she provided ear plugs / muffs?</li>
<li>Was she instructed on the proper placement of hearing protection?</li>
<li>Was she assisted in the proper placement of hearing protection?</li>
</ol>
<p>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.</p>
<p>This is at the crux of our <em>&#8216;No More&#8217; in &#8217;09</em> 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.</p>
<p>MRI accident reports have nearly <span style="text-decoration: underline;">tripled</span> 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. <em>&#8216;No More&#8217; in &#8217;09</em> means exactly what it says&#8230; 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).</p>
<p>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&#8217;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&#8217;s accident are rarely shared with the larger MRI community.</p>
<p>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.</p>
<p>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&#8217;s not a question of whether we can. It&#8217;s only a question of whether we will.</p>
<address><strong>Tobias Gilk</strong>, President &amp; MRI Safety Director</address>
<address>Mednovus, Inc.</address>
<address>Tobias.Gilk@Mednovus.com</address>
<address> <a title="Link to MEDNOVUS.com" href="http://www.mednovus.com/" target="_blank">www.MEDNOVUS.com</a></address>
]]></content:encoded>
			<wfw:commentRss>http://mrimetaldetector.com/blog/2008/12/no-more-in-09/feed/</wfw:commentRss>
		<slash:comments>0</slash:comments>
		</item>
		<item>
		<title>MRI Safety Planning Season</title>
		<link>http://mrimetaldetector.com/blog/2008/10/mri-safety-planning-season/</link>
		<comments>http://mrimetaldetector.com/blog/2008/10/mri-safety-planning-season/#comments</comments>
		<pubDate>Tue, 14 Oct 2008 20:38:53 +0000</pubDate>
		<dc:creator>Tobias Gilk</dc:creator>
				<category><![CDATA[Ferromagnetic Detection for MRI Safety]]></category>
		<category><![CDATA[ACR]]></category>
		<category><![CDATA[budget]]></category>
		<category><![CDATA[detection]]></category>
		<category><![CDATA[detector]]></category>
		<category><![CDATA[ferromagnetic]]></category>
		<category><![CDATA[fiscal]]></category>
		<category><![CDATA[Guidance Document]]></category>
		<category><![CDATA[Joint Commission]]></category>
		<category><![CDATA[Mednovus]]></category>
		<category><![CDATA[metal]]></category>
		<category><![CDATA[MR]]></category>
		<category><![CDATA[MRI]]></category>
		<category><![CDATA[plan]]></category>
		<category><![CDATA[planning]]></category>
		<category><![CDATA[safety]]></category>
		<category><![CDATA[season]]></category>
		<category><![CDATA[Sentinel Event]]></category>
		<category><![CDATA[Siemens]]></category>
		<category><![CDATA[VA]]></category>
		<category><![CDATA[Veterans Administration]]></category>

		<guid isPermaLink="false">http://mrimetaldetector.com/blog/?p=127</guid>
		<description><![CDATA[Turning leaves? Evening chill in the air? Football weekends? All classic signs that it is MRI Safety Planning Season! And in case you're not familiar with the traditional observances...]]></description>
			<content:encoded><![CDATA[<p>Ahh the four seasons&#8230; Winter, Spring, Summer, and <em>MRI Safety Planning</em>.</p>
<p>What, you&#8217;ve only heard it referred to as &#8216;<em>Autumn</em>&#8216; before? Well, that&#8217;s not terribly surprising. We&#8217;re so inundated with honorary days, weeks, and even months, that the season of <em>MRI Safety Planning</em> fails to get its fair share of media time. But here&#8217;s why <em>MRI Safety Planning</em> season should be tops on your list right now.</p>
<p>First, while there is a growing awareness of <a title="Click for the MRI Safety Week site." href="http://www.mri-planning.com/MRI-Safety_Week/MRI-Safety_Week.html" target="_blank">MRI Safety Week</a>, a single week doesn&#8217;t really afford the time needed to plan for improvements to MRI safety. Real improvements come from refinements in operations and process, coupled with effective tools and training. That sort of interdisciplinary approach often requires more than a couple days to put together.</p>
<p>Second, MRI Safety Week falls in the middle of summer when budget-wrangling loses the attention-span battle to thoughts of barbecues and coco-butter suntan lotion. It is precisely now, when so many organizations are hammering out their financial priorities for next year&#8217;s budget, that MRI safety planning should be in full-swing.</p>
<p>By combining the operations planning with the budgeting, you can reap some real multi-task benefits from these synergistic efforts, and &#8211; buoyed by the support of our whole Mednovus organization &#8211; I&#8217;m here to help you make it as productive as possible.</p>
<p>When making your MRI safety plans, it&#8217;s important to know what <strong>new</strong> criteria are going to be expected of your facility. Accrediting bodies are all looking at MRI safety in a new way, and this is starting with the Joint Commission&#8217;s <a title="Click to read about new EC requirements" href="http://mrimetaldetector.com/blog/?p=23" target="_blank">Environment of Care</a> requirements, effective January of 2009.</p>
<p>There is also the flurry of recent MRI safety Best-Practice recommendations from a number of documents, all of which should be part of the Administrator / Technologist library of reference materials.  One common element to the Joint Commission&#8217;s Sentinel Event Alert #38, the ACR&#8217;s Guidance Document for Safe MR Practices, and the recent Veterans Administration MRI Design Guide, is the recommendation for the use of ferromagnetic detection (see below).</p>
<p><img class="alignnone" title="Who recommends FMD? These three do." src="http://mripatientsafety.com/siemens/wp-content/uploads/2008/10/FMD_rec_periactoi.gif" alt="" width="600" height="144" /></p>
<p>While ferromagnetic detection systems can be readily incorporated into both new and operational MRI facilities with minimal muss &amp; fuss, even the most easily-installed and cost-effective systems typically require advanced budgetary planning.</p>
<p>The upshot? Please start thinking today about your planned MRI safety improvements for 2009 and budget accordingly.</p>
<p>Whether you’re considering the newly-released Mednovus Sentinel® GS 2.0 portals (both the 24-inch Patient Sentinel® GS 2.0 and the 48-inch Entry Sentinel® GS 2.0) or our SAFESCAN® hand-held Target Scanner™ (or the optimal combination of both), it would be a privilege to be at your service.</p>
<p>We at Mednovus are delighted to announce our new association with Siemens Medical Solutions, a world leader in MR imaging, and we encourage you to contact your local Siemens sales rep to get product quotes for your budgeting purposes. Alternatively, simply let us know where you are located, and we will put you in touch with the appropriate Mednovus product expert from Siemens&#8217; national accessories division. Contact us soon so that we can arm you with the information you need to secure MRI safety improvements in next year’s budget.</p>
<p style="padding-left: 30px;"><a title="Click to find your Rep is." href="mailto:tobias.gilk@mednovus.com?subject=Budgeting MRI Safety-Who is my Siemens accessories product expert?">Yes! Please put me in touch with the right Siemens&#8217; accessories product expert!</a></p>
<p>By reviewing your current MRI safety protocols against published best-practices, and soon-to-be accreditation standards, you can prioritize the areas for improvement in 2009. In many cases, no-cost operational changes will help you achieve your goals, but whether it&#8217;s a new MRI-friendly infusion pump, improved signage, or the thrice-recommended ferromagnetic detector, you will probably need to have a few MRI safety line-items in next year&#8217;s budget.</p>
<p>Please contact us if we can be of any assistance in helping you with your observances of MRI Safety Planning season.</p>
<address><strong>Tobias Gilk</strong>, President &amp; MRI Safety Director</address>
<address>Mednovus, Inc.</address>
<address>Tobias.Gilk@Mednovus.com</address>
<address> <a title="Link to MEDNOVUS.com" href="http://www.mednovus.com/" target="_blank">www.MEDNOVUS.com</a></address>
]]></content:encoded>
			<wfw:commentRss>http://mrimetaldetector.com/blog/2008/10/mri-safety-planning-season/feed/</wfw:commentRss>
		<slash:comments>1</slash:comments>
		</item>
	</channel>
</rss>

