Posts Tagged ‘risk’

MRI Safety Nets: The Holes We Don’t Know About

Thursday, February 26th, 2009

“You don’t know what you don’t know.”

This phrase isn’t meant to make anyone feel small. It doesn’t mean “you should know,” or “everybody else knows this,” or even that “the guy writing this knows.” This phrase is very democratic… it applies to each of us (particularly the guy writing this).

What it means is that, if our brains are libraries, even big ones, there’s only so much information that can fit inside. We may know the next 10, 100 or 1,000 books we want to add to our mental Alexandria, but we can’t want (or even hate) the book that we don’t know exists. The same is true of MRI safety.

Click to read more about protecting against MRI accidents…

“Pardon me, but could you spare $43,172?”

Wednesday, January 21st, 2009

No, this isn’t about federal banking bail-outs or corporate welfare. This is the cost, in real-world dollars, of an average single MRI projectile accident in the VA Healthcare system.

Click to read more about the costs of MRI missile accidents…

‘No More’ In ’09

Wednesday, December 31st, 2008

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…

More Than Just A Pretty Face…

Thursday, November 13th, 2008

How I long to be judged for my content… my substance… and not just how I look!

No, not me, the author, but the figurative ‘me‘, this blog…

I don’t know if you’ve ever used them, but all of the major internet search engines have tools that you can use to find images that match your search criteria. Every so often there’s a new paparazzi picture of some starlet in mid-wardrobe-malfunction or a politician with a facial expression that looks like they just smelled something awful that become the ‘it’ picture of the day.

Well, based on the number of hits our blog has been getting recently, and the image search tools that many of these hits are coming from, apparently we have a lesser ‘it’ picture, and it has nothing to do with politics or racy nudity…

It’s a picture of an ICU bed stuck to the face of an MRI.

The 'it' photo of MRI Safety

Pictures of things stuck to magnets often generate wide-eyed looks, even laughter. After all, the juxtaposition can be pretty silly. But each of these pictures is only possible because of horrible mishaps that can each result in serious injury, or even fatality.

We encourage people to find and view these pictures, not to have a larger number of viewers snicker at them. We put them up to help deflate the ‘that could never happen here’ mythology that is dangerous. If you can see magnets, floor polishers, oxygen cylinders, wheelchairs or, as above, ICU beds that look like ones in use at the hospital or imaging center, then maybe the internal monologue becomes something more like, ‘what would have to happen here for us to have a similar accident?’

Most importantly, we hope that all of these efforts work to motivate Technologists, Radiographers, Imaging Managers, Radiologists, Risk-Managers and Compliance Officers to imagine which steps they could take at their locations to reduce the likelihood of these sorts of accidents.

There are many steps that can be taken to help improve the effectiveness of pre-screening for magnet hazards. One of the most obvious is also one of the easiest, the use of ferromagnetic detectors.

We encourage you to view and share the information contained on these pages and we hope that each of these resources, even the racy pictures of MRI missile accidents, help shape improvements to MRI safety at your facilities.

After all, I’m lot more than just a pretty face…

Tobias Gilk, President & MRI Safety Director
Mednovus, Inc.
Tobias.Gilk@Mednovus.com
www.MEDNOVUS.com

Do Hand-Held Magnets = Ferromagnetic Detection?

Tuesday, August 5th, 2008

In short, no. Hand-held magnets do not do the same job that ferromagnetic detectors do.

In many MRI facilities, foreign materials brought by people to the MR suite are tested for magnetic field hazards with high strength hand-held magnets. Ones designed specifically for MRI screening are far stronger than the ones holding up my daughter’s artwork on my refrigerator. Some of these ‘test’ magnets can be 1 Tesla at the surface (10,000 gauss)!

Example of hand-held MRI test magnet

These extremely powerful hand-held magnets can help users differentiate between superficial materials that are, and are not, ferromagnetic, but the extraordinary strength of these magnets introduces a number of additional cautions which limit their use.

First, the key word in the paragraph above is ‘superficial.’ The magnetic field of all permanent magnets drops off precipitously (field strength drops with the cube of distance… double the distance and the magnetic field is cut to 1/8th the original value), so permanent magnets will be useful for distinguishing ferromagnetic materials only at or near the surface of an object. Ferromagnetic components below the surface may go undetected by a hand-held magnet, but rest assured that the MRI will find them if those objects make it into the scanner room!

Second, the potential forces exerted on a ferromagnetic body with magnetic field strengths of near 1 Tesla mean that shallow ferromagnetic material within the body of the patient could be moved, perhaps dangerously, by these very strong magnetic forces. But if the purpose of screening is to prevent accidents instead of preemptively causing them, hand-held magnets are poorly suited for patient screening.

Third, if screening medical equipment instead of patients, even some pieces of equipment designed for use in MRI scanner rooms have maximum allowable static and dynamic magnetic field values. Sticking a 1 Tesla magnet all over an anesthesia machine may wind up having some unintended consequences with regard to operation.

Lastly, 1-Tesla magnets stick hard to things. While the hand held magnets aren’t weighty, their magnetic force can require a bit of elbow-grease to get them separated from the cart or medical gas cylinder to which they got stuck. No, it’s not like it becomes epoxied on, but wielding one of these high strength permanent magnets is not a trivial affair.

Each ferromagnetic detection product has its own limitations, so I’m not attempting to state that FMD systems are the perfect solution to the hand-held magnet problem. Hand-held magnets can be useful, in a limited range of uses.

When it comes to the recommendations of the ACR Guidance Document for Safe MR Practices, or the Joint Commission Sentinel Event Alert (#38) on MRI Accidents and Injuries, or the U.S. Veterans Administration’s new MRI Design Guide, the experts all seem to have recognized the benefits of ferromagnetic detection and made a clear distinction between the new technology and the old custom of using permanent magnets to test for safety.

Tobias Gilk, President & MRI Safety Director
Mednovus, Inc.
Tobias.Gilk@Mednovus.com
www.MEDNOVUS.com