Metrasens

Reducing MRI Accidents

9 best practices that could have prevented 74% of reported injuries*

We analysed all of the MRI injury accidents reported to the FDA via their MedWatch program in 2015 and 2016 and tested which preventions would be most effective in keeping patients and staff safe.

In total we reviewed 112 MRI related injuries. 106 of these were categorized as being burns, hearing damage or injuries caused by projectiles. We looked closer at each of these incidents and evaluated whether best practice recommendations – taken from the ACR Guidance Document on MR Safe Practices (2013)* – could have helped prevent them. We’ve summarized our analysis below.

  • Number of MRI injury accidents reported to the FDA

How many incidents are reported each year?

The graph shows the numbers of injury accidents in the USA reported to the FDA each year (MR community consensus indicates that not all incidents are reported).  For our analysis we focused on those injuries reported in 2015 and 2016 only. We excluded events where there was: insufficient/no narrative; where the report was of a non-injury event; and where the injury was not from MR-specific causes.

0%

of reported injuries weanalysed were related to burns, projectiles or hearing damage

  • Burns
  • Projectiles
  • Hearing damage
  • Other
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of these incidents could have been prevented by following the 9 best practices detailed below*

Three steps that could have prevented 69%**

of MRI projectile injuries

** The 69% is actually 100%, if we look at only clinical care scenarios (excluding service-related accidents).

1

Implement a 4-Zone model linking
access to screening / supervision

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UTILIZE FERROMAGNETIC DETECTION SYSTEMS FOR ADDITIONAL SCREENING AND PROTECTION

2

UTILIZE FERROMAGNETIC DETECTION SYSTEMS FOR ADDITIONAL SCREENING AND PROTECTION

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3

LABEL OBJECTS WITHIN THE MRI SUITE FOR MR CONDITIONS / SAFETY

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Three steps that could have prevented 94%

of MRI burn injuries*

1

Provide 1cm+ air / padding between the patient and the active coil element

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1

provide 1cm+ air / padding between the patient and the active coil element

2

Remove unneeded electrical conductors (insulate remaining)

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3

Prevent skin-to-skin contact e.g. medial thighs, thumb-thigh etc

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3

Prevent skin-to-skin contact e.g. medial thighs, thumb-thigh etc

One ACR Guidance document step that could have prevented 11%

of MRI hearing damage injuries*

… plus two steps that we believe would dramatically improve patient protection
1

Require use of hearing protection for everyone in the magnet room during the exam

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2

Verify placement / effectiveness of the hearing protection

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Verify placement / effectiveness of the hearing protection

3

Provide an alternative means of hearing protection

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Watch our latest MRI Safety Webinars

Tobias Gilk webinar Metrasens

Fundamentals of MRI Safety: Satisfying The Joint Commission’s Requirements for Annual Training

Have you and your colleagues completed your Joint Commission required annual MRI safety training yet this year? Watch this exclusive webinar with Tobias Gilk to make sure you keep up to date. The webinar covers the seven main areas anyone who scans is required to have documented training in.

Dr. Frank Shellock

Understanding & Complying with The Joint Commission’s Requirements for MRI Safety

Are you aware of The Joint Commission’s guidance on MRI safety? In this webinar Dr Frank G. Shellock and Metrasens’ John Posh give a comprehensive overview of everything you need to know.

METHODOLOGY

* For this analysis we reviewed all reported adverse events. We then disqualified those where there was: insufficient (absent) narrative; report of a non-injury event (malfunction / near-miss); injury not from MR-specific causes (e.g. table pinch); and injury events that fell outside of the top three categories (i.e. burns, projectiles, hearing damage). This left a total of 112 adverse events in 2015 and 2016. Three preventions for each of the two top categories of MRI-equipment patient injury (burns and projectiles) were taken from the ACR Guidance Document on MR Safe Practices (2013). The ACR Guidance Document provides only a single prevention against hearing damage - provide hearing protection. The quantified analysis looks only at the injury prevention of that one preventative measure for hearing damage though, from the results, the other two mechanisms for hearing damage protection appear to be appropriate and prudent, given the frequency with which hearing protection is provided to patients who later report hearing damage.
** The 69% is actually 100%, if we look at only clinical care scenarios (excluding service-related accidents).

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