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…
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
Click To Read More About This Incident And How To Prevent Similar Accidents From Occurring…
Every year the ECRI Institute publishes their Top 10 health technology hazards, identifying the 10 most serious (and unintended) risks posed by our ever-increasing use of sophisticated medical devices to diagnose and treat patients. In November, the Institute released their 2010 watch list, which dedicated a Top 10 slot, and an entire page, to ferromagnetic projectiles in MRI.
For a couple of months, at least, the FDA’s MAUDE database wasn’t displaying all of the accident narratives online… This appears to have been fixed!
A number of the MRI accident reports, when the narratives weren’t appearing, were little more than the name and mailing address of the MRI manufacturer. Today, if you want to read about the MR Technologist who had a pair of scissors magnetically-impelled into his forehead, you can do so. So Click Here If You’re Curious…
That’s right. Yesterday, October 26th, the Colombini family formally accepted a settlement offer for the MRI vs. oxygen tank accident which killed their 6-year-old son in 2001. The settlement puts to rest 8 years of litigation resulting from the single largest MRI safety incident in the industry’s consciousness. And though precedent-setting verdicts won’t result, the dollar-value of the settlement will likely cause many MRI providers to sit up and take notice.
Just how much is the settlement? Click Here To Learn More About The Settlement…
Yes, I think I’ve written at least twice before about the imminent start of the trial for the civil lawsuit stemming from the Michael Colombini fatal MRI accident in 2001. And, yes, I was wrong both times before. So, I would expect nothing less than readers of this entry to take my 3rd prognostication of the start of the trial with something more than a grain of salt… perhaps an entire salt lick! But today a little birdie told me that there’s a hole in the otherwise-booked New York Supreme Court trial schedule for late October / early November and the Colombini trial may just fit right in there.
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…
I like to keep my finger on the pulse of MRI accidents and safety issues. One consequence of this is that I frequent the FDA’s MAUDE database (MAUDE is a tortured acronym for medical device user-reported mishaps). I have long criticized the FDA for their half-hearted efforts at collecting MRI accident data (which, in fairness, appears to be as much a product of congressional limitations on the FDA’s power as anything else), but MAUDE has been the only national database for these accidents that is publicly accessible.
Every so often there is an MRI accident description that is so stunning that it sends a jolt through me, reminding me why I do what I do. This is the entry that I came across just two weeks ago…
