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Lessons Learned from MRI Safety Events

  • MRI Safety (M Bock, Section Editor)
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Abstract

Although MRI is a relatively safe imaging modality as it does not require ionizing radiation, there are many unique aspects or features that make it challenging for patient safety. The constant strong magnetic field in the MRI suite is the basis of projectile incidents. There are time-varying gradient magnetic fields and radiofrequency magnetic fields that are utilized in creating the MRI images that can interact with certain implanted or indwelling devices and result in patient harm if not correctly recognized and accounted for. These may also underlie other potential adverse events in MRI, including hearing damage and burns. Although multiple safety practices are in place to prevent injury, collective human errors can “align” to allow dangerous incidents to occur. This report discusses MRI safety incidents that have occurred involving inadequate communication, medication issues, and projectiles, and includes the lessons learned and improved practices that have been instituted to help improve safety in the MRI environment.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. •• Shellock FG, Crues III JV. MRI Bioeffects, Safety and Patient Management. Biomedical Research Publishing Group; 2014. Very valuable and up to date MRI safety resource. The book’s 31 chapters, authored by leading experts in the field, include topics related to MRI basic science, many real world clinial considerations (e.g., pregnancy, gadolinium-based contrast, ferromagnetic detection systems, sedation and anesthesia), and regulatory standards and safety guidelines.

  2. Preventing accidents and injuries in the MRI suite. In: Sentinel Event Alert: Issue 38. The Joint Commission. http://www.jointcommission.org/assets/1/18/SEA_38.PDF (2008). Accessed 15 May 2015.

  3. •• Kanal E, Barkovich AJ, Bell C, Borgstede JP, Bradley WG, Jr., Froelich JW et al. ACR guidance document on MR safe practices: 2013. J Magn Reson Imaging. 2013;37:501–30. doi:10.1002/jmri.24011. The most current document from the expert panel on MRI safety providing contemporary recommendations for standard of care best practices.

  4. Gilk T, Hsdq MA, Latino RJ. MRI safety 10 years later: what can we learn from the accident that killed Michael Colombini? PSQH. 2011;8:22–3.

    Google Scholar 

  5. Chaljub G, Kramer LA, Johnson RF 3rd, Johnson RF Jr, Singh H, Crow WN. Projectile cylinder accidents resulting from the presence of ferromagnetic nitrous oxide or oxygen tanks in the MR suite. AJR Am J Roentgenol. 2001;177:27–30. doi:10.2214/ajr.177.1.1770027.

    Article  CAS  PubMed  Google Scholar 

  6. Colletti PM. Size “H” oxygen cylinder: accidental MR projectile at 1.5 Tesla. J Magn Reson Imaging. 2004;19:141–3. doi:10.1002/jmri.10431.

    Article  PubMed  Google Scholar 

  7. Mufti S, Sheikh MA, Hakim A, Mufti SA, Jan F. A “Near-Miss Lethal Accident Case” in MR Suit of a Tertiary Care Hospital. Case Rep Radiol. 2011;2011:793570. doi:10.1155/2011/793570.

    PubMed Central  PubMed  Google Scholar 

  8. FDA. MAUDE—Manufacturer and User Facility Device Experience. U.S. Food and Drug Administration. http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/Search.cfm (2015). Accessed 11 May 2015.

  9. • Henderson JM, Tkach J, Phillips M, Baker K, Shellock FG, Rezai AR. Permanent neurological deficit related to magnetic resonance imaging in a patient with implanted deep brain stimulation electrodes for Parkinson’s disease: case report. Neurosurgery. 2005;57:E1063; discussion E. Illustrative case report demonstrating clinical consequences of an MRI safety accident in which scanning was performed outside the MRI conditional guidelines for a deep brain stimulation system.

  10. To err is human: Building a safer health system. Institute of Medicine. http://www.nap.edu/books/0309068371/html/ (1999). Accessed 11 May 2015.

  11. Schultz SR, Watson RE Jr, Prescott SL, Krecke KN, Aakre KT, Islam MN, et al. Patient safety event reporting in a large radiology department. AJR Am J Roentgenol. 2011;197:684–8. doi:10.2214/AJR.11.6718.

    Article  PubMed  Google Scholar 

  12. Abujudeh HH, Kaewlai R. Radiology failure mode and effect analysis: what is it? Radiology. 2009;252:544–50. doi:10.1148/radiol.2522081954.

    Article  PubMed  Google Scholar 

  13. Choksi VR, Marn CS, Bell Y, Carlos R. Efficiency of a semiautomated coding and review process for notification of critical findings in diagnostic imaging. AJR Am J Roentgenol. 2006;186:933–6. doi:10.2214/AJR.04.1913.

    Article  PubMed  Google Scholar 

  14. • Reason J. Human error. Cambridge: Cambridge University Press; 1990. The source of the “swiss chsses model” of error propagation. This method of analysis was used extensively in the airline industry in accident investigation, and has been used increasingly in health care settings.

  15. Watson R, Cradick C, Epps S, Mauck W, Luetmer P. Implementing an EHR medical device module - a critical patient safety enhancement. American College of Radiology Annual Meeting; May; Washington D.C. 2015.

  16. Higgins JV, Gard JJ, Sheldon SH, Espinosa RE, Wood CP, Felmlee JP, et al. Safety and outcomes of magnetic resonance imaging in patients with abandoned pacemaker and defibrillator leads. Pacing Clin Electrophysiol. 2014;37:1284–90. doi:10.1111/pace.12419.

    Article  PubMed  Google Scholar 

  17. • Langman DA, Goldberg IB, Finn JP, Ennis DB. Pacemaker lead tip heating in abandoned and pacemaker-attached leads at 1.5 Tesla MRI. J Magn Reson Imaging. 2011;33:426–31. doi:10.1002/jmri.22463. Illustrative paper demonstrating pronounced capacity for heating of implanted leads that can be a function of field strength and length of the lead.

  18. Kalin R, Stanton MS. Current clinical issues for MRI scanning of pacemaker and defibrillator patients. Pacing Clin Electrophysiol. 2005;28:326–8. doi:10.1111/j.1540-8159.2005.50024.x.

    Article  PubMed  Google Scholar 

  19. Spinazzi A. MRI contrast agents and nephrogenic systemic fibrosis. In: Shellock FG, Crues III JV, editors. MRI bioeffects, safety, and patient management. Los Angeles, CA: Biomedical Research Publishing Group; 2014. p. 256–81.

    Google Scholar 

  20. McDonald RJ, McDonald JS, Kallmes DF, Jentoft ME, Murray DL, Thielen KR, et al. Intracranial gadolinium deposition after contrast-enhanced MR imaging. Radiology. 2015;. doi:10.1148/radiol.15150025.

    Google Scholar 

  21. Kanda T, Fukusato T, Matsuda M, Toyoda K, Oba H, Kotoku J, et al. Gadolinium-based contrast agent accumulates in the brain even in subjects without severe renal dysfunction: evaluation of autopsy brain specimens with inductively coupled plasma mass spectroscopy. Radiology. 2015;. doi:10.1148/radiol.2015142690.

    Google Scholar 

  22. • Kanal E, Tweedle MF. Residual or retained gadolinium: practical implications for radiologists and our patients. Radiology. 2015;275:630–4. doi:10.1148/radiol.2015150805. Recent thoughtful commentary on emerging evidence and implications of identifying retained gadolinium in patients in the absence of renal failure.

  23. Food and Drug Administration Public Health Advisory: Risk of Burns during MRI Scans from Transdermal Drug Patches with Metallic Backings. FDA. http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/DrugSafetyInformationforHeathcareProfessionals/PublicHealthAdvisories/ucm111313.htm (2009). Accessed 15 May 2015.

  24. Kanal E. Implementation: documentation in MRI safety. MRI Patient Safety Blog: WordPress; 2014. http://mripatientsafety.com/blog/?p=285. Accessed 15 May 2015.

  25. Wynn K. Man stabbed in eye during brain scan, The New Zealand Herald, 2014. http://m.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=11359290. Accessed 15 May 2015.

  26. Shellock FG, Kanal E, Gilk TB. Regarding the value reported for the term “spatial gradient magnetic field” and how this information is applied to labeling of medical implants and devices. AJR Am J Roentgenol. 2011;196:142–5. doi:10.2214/AJR.10.5004.

    Article  PubMed  Google Scholar 

  27. Serious Reportable Events. National Quality Forum. http://www.qualityforum.org/Show_Content.aspx?id=69569 (2015). Accessed 15 May 2015.

  28. List of SREs. National Quality Forum. http://www.qualityforum.org/Topics/SREs/List_of_SREs.aspx (2011). Accessed 15 May 2015.

  29. Angle JF, Nemcek AA Jr, Cohen AM, Miller DL, Grassi CJ, D’Agostino HR, et al. Quality improvement guidelines for preventing wrong site, wrong procedure, and wrong person errors: application of the joint commission “Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery” to the practice of interventional radiology. J Vasc Interv Radiol. 2008;19:1145–51. doi:10.1016/j.jvir.2008.03.027.

    Article  PubMed  Google Scholar 

  30. Gilk T. MRI Safety: Professionals, practice, credentialing. In: HealthManagement.org. https://healthmanagement.org/c/healthmanagement/issuearticle/mri-safety-professionals-practice-credentialing (2015). Accessed 15 May 2015.

  31. Brosnan DP. Human error and structural engineering. Str Mag. 2008;September:46–9.

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Acknowledgments

The author thanks Sonia Watson, Ph.D. for assistance in editing the manuscript.

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Authors and Affiliations

  1. Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA

    Robert E. Watson

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  1. Robert E. Watson
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Correspondence to Robert E. Watson.

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This article is part of the Topical Collection on MRI Safety.

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Watson, R.E. Lessons Learned from MRI Safety Events. Curr Radiol Rep 3, 37 (2015). https://doi.org/10.1007/s40134-015-0122-z

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