Yesterday I was provided a copy of an anonymized MRI accident / incident report which described how an MRI patient wearing a ThermaCare HeatWrap (something of a self-warming patch for muscle aches) had the wrap pulled off of them by the magnetic attraction of the MRI.
ThermaCare HeatWrap Products Contain Iron And May Be Drawn Into MRI Scanners
For those unfamiliar with the term, a ‘never event’ is a label used to describe an adverse event that is wholly avoidable by simply following established best practices. For example, if you have an accurate count of the surgical instruments before and after surgery, there should never be an event where the patient leaves the OR with a sponge or clamp sewn up inside of them. A retained surgical instrument, or wrong-site surgery, or bed-sores, or patient mis-identification, or medication errors are all examples of ‘never events’.
Some insurance payers are beginning to refuse reimbursement for care that is necessitated by certain ‘never events’, and that list is likely to grow. And while they may not always result in patient injury, I’d like to propose my own list of 5 MRI ‘never events’ which should at least trigger an investigation…
When I was eight, these words struck fear in my heart. It didn’t matter how small the infraction I committed was (or if there even was an infraction to begin with), I would beg the other kid to not ‘tell’ whoever it was that they were planning to tell. It may have been their kindly grandmother that they planned on telling, but in my mind it was always some 7-foot troll who would have undoubtedly come outside and chewed me to bits.
It took a while, but slowly I realized that tellin‘ and getting in trouble were two, very different things. This is a lesson that we in the MRI community would do well to learn regarding accidents.