Tag Archives: patient

2011 nPSG.11.01 (nuclear-Magnetic-Resonance Patient Safety Goal)

I hope my 2011 nPSG on MRI safety doesn’t cause any confusion with the Joint Commission’s new NPSG (National Patient Safety Goals). The fact is that this is distinct… it only uses the Joint Commission’s own wording to craft a patient safety goal specific to MRI in an effort to break through the paper-thin fallacy of ‘supporting MRI safety’ without providing (a) specific standards, (b) comparable scrutiny based on TJC published best-practices, (c) enforcement of requisite risk-management standards as they would apply to MRI, or (d) specific expert training on MRI safety issues for their on-site surveyor corps.

So, here is the justification my new nPSG, using the Joint Commission’s own words… Click Here To Read TJC’s Own Words On MRI Safety…

Radiology Safety

Make no mistake, I believe that healthcare has a special obligation to protect the well being of our patients, our beneficiaries, our charges. When it comes to radiology, nuclear medicine and radiation therapy (where treating the patient involves sticking them in an astoundingly complex machine and exercising advanced concepts in physics to have a computer reconstruct fragments of data into an intelligible picture)… well its just so damned complicated that we have to assume the full responsibility for patient safety because, under those circumstances, it is wholly unreasonable to expect the patient to be active participants in their own safety.

Click To Read More About Our Special Radiology Safety Duty…

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…

I Love Being Wrong…

Alright, I don’t love the fact of being wrong, but my mission is to motivate improvements in MRI safety for patients, staff, and providers. I’m not the least bit interested in having the longest list of ‘I told you so’ moments, and I’m uncomfortable when someone applies the term ‘guru’ to me. I am openly, vocally, critical of organizations when I feel that they haven’t lived up to their obligation to reinforce MRI safety standards, so when one of them does well, I can’t tell you how happy I am to eat my prior words, and today is an example of that…

Click To Read Who Tobias Was Wrong About…

30% Of Contraindicated Implant Patients Get MRIs Anyway!

And what’s even more alarming is that 20% of those implant patients that get MRIs experience some sort of device malfunction afterward! And yet, the dangers of imaging these patients are not well known by the doctors who prescribe these imaging studies.

Click To Learn Just How Many Doctors and Patients Are Ill-Informed Of These Risks…

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…

$2.9 Million Settlement Closes Colombini MRI Death Case

This week the settlement documents were released — 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.

Click To Learn More About The Accident And Settlement…

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…