According to the news accounts, her concerns about something having been left in her from the surgery were laughed-off: “The times of leaving instruments inside you are long gone.”

Returning to her own hospital, she got an X-ray which showed just how wrong that statement is…

X-ray Image Showing Forceps. Image From www.thesun.co.uk

As I mentioned in the article on the restoration of the full MAUDE narratives, I filed a Freedom of Information Act (FOI) request for the data, motivated by a concern that the problem with the online database would not be resolved in a timely fashion. Below are a handful of PDF files from my FOI request, enumerating just MRI projectile accidents (one of the five types of MRI ‘never events’) from part of the 2009 data…

• Bed tray-table (ambiguous injuries, including facial lacerations)

• Rolling cart seriously injures Siemens Apps Specialist (facial fractures & brain trauma)

• Flat-screen monitor hits research subject (facial fractures & surgery)

• Patient on gurney gets more of a ride than planned (foot, ankle, leg fractures)

• IV cart nearly strikes patient (near-miss)

• Knife slices patient (laceration requiring stitches)

• ‘Sand’ bag injures patient (brain hemorrhage, tongue laceration and facial injuries)

• Scissors seriously injures tech (embedded in forehead, surgical removal required)

The length and scariness of this list says two things to me… 1. Even without correcting for the presumed 1% reporting rate, this list is already too long suggesting that we have a long way to go, and 2. Why aren’t we taking a more proactive role in preventing these sorts of accidents when there are tools and techniques readily available?

Is it that crushing facial injuries, brain trauma and scissors embedded in someone’s forehead are collectively ‘minor exceptions’ even when these events (and many others) occur within weeks of one another?

To answer the rhetorical question posed by the title of this post, absolutely we continue to call them ‘never events’ because they should never happen. The fact that we have a long way to go to get close to that frequency is not an indictment of the validity of the goal, but it is a reason to call for professional / regulatory change if the industry can’t close the gap on its own.

The article describes how the boy was wrapped in a metallic ‘space blanket’ during the exam, and yet the 3rd degree burn was attributed (by the hospital administration) to ‘trapped heat’ in the cotton blanket that came from a blanket warmer.

Example of Space Blanket

Though it may have taken a little ‘nudging’ to get a formal commitment on the part of the hospital to cover the costs of all treatment associated with the burn, it is the least that should be done to offset the injury that was caused by a failure to follow industry standard screening protocols.

Hopefully this incident will also trigger a review of MRI protocols and procedures at this facility, too. Often the ‘it’ll never happen here’ attitude persists even after an incident (morphing, ever so smoothly, into ‘it’ll never happen here again‘), with little effectively done to reduce the risks of recurrence.

And as I am a firm believer in the gold-plated opportunity that is presented every time we learn of any mistake (our own or others’), I hope that MRI providers around the world look at this incident as one more validating event that periodic reviews of our safety policies is not just a good idea, it’s absolutely necessary in such a dynamic area as MRI.

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…

#5 Unauthorized Access: If any person, patient, visitor or staff member, gains access to the restricted areas of the MRI suite (Zones III and IV) without having been appropriately screened and supervised, this should raise red-flags and be the impetus for a review of the physical protections and operational protocols. Too often, because these safety-symptoms don’t immediately result in injury, they are disregarded as harmless, which couldn’t be further from the truth. If unscreened people or equipment are making it into the controlled access areas of the MRI suite, it’s only a matter of time before one of them is involved in a real accident.

#4 NSF / Renal Function Screening: A year ago, this may have appeared as the #1 item on this list, but the fact is that, today, many facilities are doing a great job of this. Essentially, we need to provide, at a minimum, a renal function risk-factor screening for every patient prior to being administered Gadolinium-based contrast agents. And, minimally, for patients identified as falling within one of the higher-risk profiles, a calculated eGFR should be taken for verification of patient risk and to inform the treatment of that patient. As with the #5 never event above, the failure to provide effective screening, even if it doesn’t result in an adverse outcome, is enough to warrant a review of operational protocols.

#3 Contraindicated Implants: There are times when, as a concurrent result of poor patient history / records, and inconspicuous (or absent) indicators for medical devices, patients (or visitors) enter the MRI scanner room with contraindicated devices. Nobody expects MR Technologists to be omniscient about what is on or inside their patients, but it is critical that we provide an appropriately thorough screening for the circumstances to try and ascertain whether the patient has any of the potpourri of shunts, pacers, stimulators, clips, pins, plates, etc… that may be dangerous to them. Any failure to use the appropriate means available to identify contraindications should, minimally, spur an evaluation of policies & procedures.

#2 RF Burns: This one factor may be the fastest-growing source of patient injury in MRI. By verifying that unneeded coils and leads are removed, that remaining leads are appropriately positioned and insulated from the patient, that the patient’s body is not positioned to form large-caliber loops, and that there is appropriate distance / insulation between the patient and any transmitting RF coils are all integral, requisite elements to minimizing the risks of MR burns. A failure to follow the appropriate steps to protect the patient, even if the shortcut doesn’t result in a visible burn, should (as with the proceeding never events) trigger a review of operational procedures.

#1 Projectiles / Missiles: Screening protocols should do everything to make sure that ferromagnetic materials are not brought into the MRI scanner room. Any discovered ferromagnetic material inside the MRI room indicates a breakdown in screening and presents all of the ingredients for injury or equipment damage. Particularly for MRI providers that don’t gown all of their patients, the use of a ferromagnetic detector is more than just recommended, it is codified in the ACR Guidance Document for Safe MR Practices as a part of the MR safety best practice. And as with all of the MRI never events before #1, any discovery of a ferromagnetic threat inside the magnet room should trigger a review of existing protections, operations and protocols.

While these 5 don’t encompass all of MRI safety, they do clearly represent 5 of the most common (and most avoidable) hazards in the MRI environment. MRI providers should have rigorous protocols and protections to minimize these risks to patients, staff, visitors and, in the case of projectile accidents, millions of dollars of MRI equipment.

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.