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Why 100% Preventable MRI Accidents Still Happen

  Jun 25th, 2015   -     MRI Safety   -  

If you run an MR operation, you’re probably under pressure to bill more procedures per day. And Marketing’s in your ear, too, telling you how to build a brand around convenience and comfort for patients. Here’s how to balance these goals while keeping MRI safety for patients the #1 priority.   Our faculty hears it all the time from MR suite supervisors and techs: There’s constant pressure from above to get scans done faster, and with minimum inconvenience to patients. Screen them quickly. Let them wear their own clothes when possible. Don’t waste their time.   It’s about optimizing the “patient experience” and, of course, the bottom line. And this makes perfect sense — as long as safety isn’t compromised.   Unfortunately, it appears that MR safety has been increasingly compromised in recent years. From 2000 to 2013, adverse MRI events reported to the FDA grew 487%. During that same period, according to the market research firm, IMV, MRI usage increased only 112%.   These numbers look bad enough as it is, but let’s not forget, they only measure what providers voluntarily report. The true number of incidents — and their cost in dollars and suffering — we’ll probably never know.   4 Steps to Safer MR Operations We spoke with two of our faculty members, both among the most respected MR safety experts in the business, for ideas about how your MR operation can help reverse our industry’s track record.  
  1. Reverse the cultural headwinds. Bill Faulkner, consultant, author of textbooks for MRI techs, and founding member of the American Board of Magnetic Resonance Safety (ABMRS), says the attitude toward safety in an MR suite starts at the top.
  Someone in authority must be responsible for counterbalancing the prevailing, profit-driven culture. “You need to have a specific person accountable for a safe MR environment,” Faulker says. “This person must know the day-to-day, hands-on procedures, and be responsible for establishing written safety policies and procedures.” Faulkner adds that written procedures are only as good as the training the staff receives in how to follow the procedures, including what to do in an emergency. Safety leadership should also come from radiologists, Faulkner points out. “They’re the doctors in charge of this technology, and they have a unique liability exposure. Often the patients don’t even see them, and it’s easier to sue someone you’ve never met,” he says.  
  1. Balance safety and convenience. Sometimes, in an MR environment, safety simply isn’t convenient. That’s a key message of Faulkner and his associate, Kristan Harrington, who designs and teaches university MRI degree curriculums.
  As Harrington often tells medical facility administrators and MR staffers in seminars and audit reviews: “This is NOT a day spa — this is a hospital. An MRI is a medical procedure using  potentially very dangerous apparatus. We must always treat it that way.”   But that’s getting more difficult in many MR facilities, Harrington says..   She recalls when doing a complete head scan and a complete spine scan for one patient was supposed to take two hours. “Now the staff is usually expected to do both in one hour. At the same time, the staffing has been cut back,” she says.   One way to speed up procedures and make patients happy at the same time is to allow patients to wear their own clothing during a scan. Harrington warns against this, even when a screening shows no apparent risks.   “MR staffs tell people to come in wearing sports attire, but the newer garments have metal micro-fibers that can burn the patient’s skin when MR waves heat it up,” Harrington says. “Most of the adverse incidents I see now are burns from clothing.”  
  1. Report “near incidents” and learn from them. Bill Faulkner recently spoke with an MR tech who told him about a patient who’d been scanned without the techs being aware if the patient’s pacemaker. Two techs handled the scan, and each thought the other had done the screening.
  Techs also tell Faulkner about nurse’s aides and other hospital staffers who approach open MR suite doors with oxygen tanks and other metallic objects that can quickly turn into lethal projectiles.   Don’t sweep these “near incidents” under the table, as many facilities do, Faulker advises. “You can’t tolerate negligence or incompetence, but you need to encourage people to come forward so you can use this information to train others, and to correct faulty policies or procedures,” he says.  
  1. Get certified. Stay certified. Obviously, as MRI safety consultants and trainers, Faulkner and Harrington stress that MR staffs have their certifications up to date. It’s simple: Better trained MR professionals are safer professionals.
  As part of establishing your safety leadership position, be sure someone is responsible for tracking the certification of everyone involved with administering MR procedures.   In addition to continuing medical education courses, set up at least a brief internal training session aimed at helping MR staffers understand the business team’s needs, and vice-versa. The cultures of safety and business don’t have to clash, as long as both value the patient’s well-being above all.