I was invited to present a paper at the American College of Radiology’s meeting on quality and safety held October 22 – 23 in Phoenix, Arizona. Actually, the invitation came in response to an abstract of a paper that hadn’t been written yet [not to self, don't promise papers you've not yet written again].

While the FDA’s adverse event data was clearly never intended to be useful to the outside world (we eliminated over 50% of the events from consideration, primarily because of too little narrative), it did provide a great snapshot of the diversity of accidents. We wound up with 104 useful event reports from an 18 month period of reporting.

We then compared each of these 104 events against the criteria in both the ACR Guidance Document and the Joint Commission Sentinel Event Alert #38. What we found gave us tremendous encouragement… encouragement tempered with some very unpleasant contemporary realities.

Stunning: Our review found that the ACR Guidance Document for Safe MR Practices: 2007 had explicit, actionable criteria that could have interdicted 80% of the 104 tested adverse events! And that doesn’t even include the general provisions for safety such as technologist training, or situational awareness.

The TJC Sentinel Event Alert (SEA) #38 fared somewhat less well, with a 49% effectiveness, though preventing half of the MRI adverse events that are occurring is certainly nothing to scoff at!

Frustrating: Neither the ACR nor the Joint Commission currently have any… ANY… explicit standards for MRI safety, despite the fact that each organization has published best-practice standards that promise to be 80% and 49% effective (respectively) in mitigating MR specific hazards in the MRI suite!

So the conclusion of the presentation offers a challenge to the ACR, the Joint Commission, DNV, and the IAC, to adopt explicit MRI safety standards as a requisite element of accreditation.

If you would like to view the presentation, please see the video (below).

http://www.youtube.com/watch?v=O4zsQ1Yh15A

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Ferromagnetic detection doesn’t catch anything that existing screening protocols aren’t meant to catch.

That inflection makes a world of difference, as you’ll see in just a moment…

We’ve been screening for ferromagnetic materials as long as MRI has existed, but our historic technique of simply asking if someone has magnetic materials has not proven very effective. There are many accounts of magnet damage, injuries, and fatalities resulting from a failure to identify ferromagnetic materials before they were brought into the MRI room. And despite a universal familiarity with the risks of ferromagnetic materials, we as an industry seem unable to prevent them from recurring by using only these ‘old school’ screening protocols.

There was a policy in place to screen for ferromagnetic materials at this New York hospital in 2001:

And they had a policy to screen for ferromagnetic materials at this Seattle hospital in 2005:

They had a policy to screen for ferromagnetic materials at this hospital:

And here:

And here:

And here:

And here:

And here:

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And lots, and lots of places that you can see here:

Honestly, I could drown you in pictures and accounts of ferromagnetic materials in the MRI suite. Suffice it to say that the accounts above are only the tip of the iceberg.

One of the most ironic (in light of what you’ve seen above) arguments against the need for ferromagnetic detection is that it isn’t foolproof.

Foolproof!?!? If that’s the standard, how can we reconcile the results of our conventional screening practices against this expectation of perfection? Clearly, we’re a very, very long way from that goal.

Instead of willfully disbelieving everything shown above… Instead of insisting on the infallibility of patient and visitor compliance with screening instructions, or the unblinking door-watching vigilance of the Technologists, or the guaranteed long-term effectiveness of MRI safety training for housekeeping, transport, engineering, security, anesthesia, ICU and respiratory staff, why can’t we accept that each of these protections, as valuable as they are, are imperfect, and that if maximum safety is our goal, we need to augment these long-standing – and incomplete – strategies with something new.

I freely state that ferromagnetic detection is not perfect. Under certain circumstances, it can miss things that we may want to find. It does, however, provide us with an entirely new feedback mechanism that helps us to more effectively monitor, train, screen, and protect people in the MRI environment. Imperfect though it is, it is remarkably effective at helping to improve the safety of everyone inside the MRI suite.

PS: I would like to thank the following people who have helped me by providing some of the images you’ve seen above, Moriel Ness Aiver, Raj Sangoi, and Keith Del Guercio.

But then, typically after I’ve lost all hope of seeing anything that approaches reality, something plausible and even downright real is shown on one of these programs…

OK, so there are probably 100 unreal aspects to the above clip (like MD’s, even though they’re residents, bringing the patient to the MR to run the scan themselves). But the main message, the patient bed being drawn to the MR, is a concern. And the concern is not theoretical, but is in fact quite real.

Beyond the above photo, an anecdote was shared with me by a trusted source of an accident somewhat similar to the video clip above.

In the story, an end-stage AIDS patient in a hospital is brought down for an MRI and, like in the video, is transported into the MRI scanner room on a conventional hospital bed. As in the video, the magnet attracts the bed which rolls across the floor until it strikes face of the MRI machine. The impact of the front end of the bed (where the patient’s feet are) against the machine causes the back end of the bed (where the patient’s head is) to lift up off the ground momentarily. The magnetic field of the MRI is pulling on the back end of the bed, however, and essentially catapults the back end of the bed over the front end, smashing the patient’s face and upper-body against the outside of the MRI scanner.

According to my source, the patient died a couple days later and the official cause of death was identified as ‘complications from AIDS’ and there was no explanation offered for the severe facial contusions and fractures that were present at the time of death.

Now, I wouldn’t suggest that you take every fish-story you hear at face value, but the more I learn about the breadth and breathtaking frequency of MRI projectile accidents, the less skeptical I’ve become about the relative ‘impossibility’ of the anecdotes I’ve heard. Some of the most outlandish and improbable have proven to be true.

Per the aphorism, “as soon as you make something foolproof, they come out with a better fool,” there is no way to 100% prevent projectile accidents in the MRI suite. However, the fact that we can’t make a safety solution ‘foolproof’ is no reason to reject the healthy improvement that we can make with improvements to process and technology.

Appropriate staffing levels, regular MR staff training, access controls tied to screening protocols, and ferromagnetic detection systems all help to reduce the risks of projectile accidents in the MRI suite. The first three of these four options have been well known elements of MRI safety for years, and yet projectile accidents keep occurring and the overall rates of MRI accidents appears to be climbing… alarmingly.

Simply put, we have the ability to make these sorts of accidents largely fictional, left to ER and House, but we haven’t done so. And when prime-time television is more honest about MRI accidents than the industry is (even if their honesty is purely coincidental), we’ve all got a way to go.

Among the ACR Guidance Document on Safe MR Practices: 2007, the recent Joint Commission Sentinel Event Alert #38 on MRI Accidents and Injuries, and other standards and expert recommendations, it is abundantly clear that ferromagnetic detection is a potent part of an effective MR screening program.

A PDF transcript of the above video is available for download at http://MRImetaldetector.com/blog/wp-content/uploads/Transcript_of_Dr_Kanal_Edited_video.pdf.

As everyone who’s spent more than an hour or two around an MRI knows, these super high-strength magnets have a reputation for ‘sucking-in’ ferromagnetic materials that are so prevalent in wheelchairs, gurneys, gas cylinders, fire extinguisher, and carts.

In the last few years, there’s been a spate of floor polishers that have found their way into MRI scanners across the country…

But while there’s a nearly universal urge to snicker at these images, it is important to realize two crucial things about each and every projectile accident.

First: Each and every MRI missile effect accident is theoretically 100% avoidable. By prospectively identifying the ferromagnetic nature of materials before they’re brought into the MRI suite, none of these need to happen. By following best practices including the ACR’s Guidance Document, or the Joint Commission Sentinel Event Alert, and deploying ferromagnetic detection screening of all people and materials approaching the MRI scanner, it is possible to prevent projectile accidents.

Second: Each and every ferromagnetic projectile incident has all the ingredients for injury. While there is only one official account of a projectile-related fatality, there are many, many reports of injury, a good number of which have been severe. And given the abysmal rates of MRI accident reporting, it’s entirely believable that other anecdotal accounts of MRI-projectile fatalities are more fact than fiction.

These projectile accidents are more commonplace, and more dangerous than many are aware. So what can you can do to avoid becoming a part of the MRI missile accident scrapbook? Start by reviewing all of your MRI safety protocols, and consider deploying ferromagnetic detection screening for each and every MRI.

PS: If you’d like to find more pictures, and even a video or two, on MRI accidents, I encourage you to check out www.SimplyPhysics.com/flying_objects.html

The full video (from which the still above was taken) is available at the Imagylis website (http://www.patiencys.com/mri-safety/). The MRI patient screening video is also available at the same website, but on its own page (http://www.patiencys.com/mri/).

Maybe, with all of the recommendations for the use of ferromagnetic detection, they’ll recreate the accident video to demonstrate how how such an accident might be averted with the effective use of ferromagnetic detection.

In order for that accident to occur, a few standard procedures had to go awry, and not in ways that you might think. The anesthesiologist’s primary goal was to get his patient oxygen. The Technologists’ primary goal was to figure out why the oxygen (which the anesthesiologist was yelling for) wasn’t working. The nurse passing the MRI unit’s primary goal was to help out when she heard someone calling for help. This accident, like so many others, was the product of well-intended efforts in an environment where the rules are all imperceptibly changed.

There were a number of interventions that could have potentially broken the chain of events that resulted in this fatality. Better access controls, more effective training for the Technologists and anesthesiologist, storage to keep hazardous ferromagnetic materials out of sight, suitable portable cylinders, better QA/QC on the medical gas system… each of these might have been enough to avert this accident.

Add to this list the effective use of ferromagnetic detection, which might have provided the automatic feedback needed to sequester the fatal oxygen cylinder before the MRI exam even began, or remind the anesthesiologist of which materials were dangerous near the magnet, or provide warning feedback to the nurse who let herself into the suite.

As the Colombini accident illustrates, projectile accidents in the MRI suite are most often the result of multiple factors. Effectively interdicting these sorts of accidents requires vigilance on many fronts. While there are no ‘silver bullet’ solutions to MRI risks, no one product or training session that can eliminate the risks, there are products and solutions that help to minimize the risks. Most of the solutions have been around nearly as long as MRI, but only recently has ferromagnetic detection been added to the MR safety armamentarium.

This new ferromagnetic-only detection technology substantially increases the opportunity for Technologists and MR-staff to find and quarantine ferromagnetic threats worn by, or carried by, persons approaching the MRI magnet. In a forthcoming post I’ll describe the flurry of recent ‘best practice’ standards that all now call for the use of ferromagnetic detection to improve MRI safety.

UPDATE: Details of the finalized lawsuit settlement are available here.

Here’s a perfect example that made the local news in Seattle a few years ago…

$200,000! And that was probably just the repair bill and didn’t count the ongoing expenses such as the scheduled staff’s salaries, the cost of the machine and the service contract (which, by the way, wouldn’t cover this type of accident), and the $1,000 per hour that the hospital failed to bring in by performing MRI scans.

“Uhh, Mr. Jones we could probably squeeze you in if you don’t mind if we cover your body in Crisco so that we can slide you past the floor polisher that’s wedged in the front of the opening to the MRI scanner.”

And at $10,000 – $15,000 per day in lost revenue (and probably something approaching that for ongoing operational expenses) the immediate indirect costs probably start to rival the direct repair costs. Then add on the fact that the accident made the evening news. How many patients over the next several days and weeks canceled their appointments (or worse, simply didn’t show up) out of a fear that the MRI at the hospital was unsafe??

The shocking truth is that these sorts of accidents occur all the time. MRI providers can be faced with up to a half-million dollars in costs just from one overzealous housekeeper with a floor polisher.

Why do floor polishers and oxygen cylinders (and a whole laundry list of other items) repeatedly get sucked into magnets and cause so much damage? It’s usually because people are either unaware of the fact that there is a risk from these super-strong magnets, or because they mistakenly think that the object that they’re carrying is safe in the MRI room. In either case, a ferromagnetic detector could provide the feedback needed to alert the patient, support staff or physician that they have something on their person that may prove to be a major threat to the MRI scanner.