Tag Archives: never event

MRI ‘Finds’ Forceps Left In Surgical Patient

News broke the other day of a nurse in England who was in agony for three months following a routine surgery during which her gall-bladder was removed. Fearing an infection, she was sent for an MRI. Unfortunately, the MRI could not be completed as the magnetic field began torquing the 7-inch pair of forceps that had been left inside her abdomen during the surgery, causing excruciating pain! Click Here For The Follow-Up X-ray And The Rest Of The Story…

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…

MRI ‘Never Event’ In Athens, Alabama

The Athens, Alabama, News Courier ran a story December 4th on their website about a 21-month boy who received a 3rd degree burn from an MRI. This hits square in the middle of the 5 MRI ‘never events’ that were enumerated a few months ago here on this blog.

Click For Details And A Link To The Source Article…

5 MRI ‘Never Events’

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…

Click To Read The 5 MRI Never Events…

‘No More’ In ’09

With around 8,000 – 10,000 MRI’s in the US alone, I’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.

Click to read about your part in the ‘No More’ campaign…