While they released a Sentinel Event Alert on MRI safety in 2008, and while they’ve interpreted MRI-specific applications of a couple of hospital-wide standards (mainly, non-magnetic portable fire extinguishers), it was this past December (2013) when they announced their first explicit MRI Safety Standards, which become effective in July of 2014.
There are a few highly-specific criteria that don’t leave much to interpretation (collect data on your failed screenings in which a ferromagnetic object was allowed to enter the MRI scanner room), and there are more somewhat ambiguously-worded standards (manage MRI safety risks). Any facility that has undergone more than one Joint Commission survey knows that there is often different emphasis from one survey to the next, even if the standards haven’t changed. What follows is my own, personal, compliance checklist of the new MRI standards. While not reviewed / approved / sanctioned / blessed by the Joint Commission, I would contend that anyone who can check all of these boxes should sail through any survey that uses the new MRI safety standards… Continue reading →
I apologize for my unusually long hiatus from posting. I’d love to tell you that I haven’t written because I’ve been so extraordinarily busy putting the final touches on a set of meaningful standards which will effectively protect the 30,000,000 (that’s million) annual MRI patients in the U.S. from the most frequent preventable MRI injuries. I’d love to tell you that, but it’d be a lie… Continue reading →
It’s almost enough to bring my high school English teacher back from the dead… me, railing on someone else’s vocabulary skills. What I’m talking about here is the new Revo pacemaker (formerly known as Enrhythm) by Medtronic, designed to allow pacemaker patients to receive MRI scans.
This past weekend I was invited to present the findings of a study I did with my friend and colleague, Emanuel Kanal. Among his many accolades and credentials, Manny Kanal is the Chair of the ACR MR Safety Committee, a fellow of the ACR and ISMRM, and a neuroradiologist at the University of Pittsburgh Medical Center. The study had a two-part mission, first to review and categorize 18 months of the FDA’s MRI accident data, and second to compare each of these adverse events against existing best-practice standards for MRI safety. The results of the analysis were both stunning, and disheartening…
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.
This, in essence, is the entirety of point-of-care safety standards for MRI.
“Hey, you, MR technologist! Make sure you know what you’re supposed to know to keep people safe around MRI.“
Make no mistake, as someone who spent a decade in college (which included a Masters degree and about half of a 2nd Bachelors), I’m a huge fan of education. What I’m adamantly opposed to – when it comes to MRI safety – is education without any standards or benchmarks, which is precisely where we find ourselves today.
Color me flattered! (which I think is the color of that shirt in the illustration)
Wired UK Illustration by Lee Hasler. Click for Wired UK source.
The UK edition of Wired magazine just ran one of their ‘featurettes’ on this blog and picked their favorite (though, that’s a slightly squint word-choice for potentially deadly accidents) types of projectile accidents. Quote’s from — and a direct link to — the article follow.
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…
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.