A 3-year review of MRI safety incidents within a UK independent sector provider of diagnostic services

Hudson, Darren; Jones, Andrew

doi:10.1259/bjro.20180006

Cited by 8 publications

(8 citation statements)

References 20 publications

(45 reference statements)

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“…The risk of thermal injuries happening is primarily controlled through the design of the scanning equipment and whilst performing the examination. 6 Use of normal mode specific absorption rate (SAR) level during scanning is advocated for routine use which limits the whole body SAR to 2 Watts/kg, which in turn limits the rise in whole body temperature to no more than 0.5°C. 7 The indirect effects of heating are effectively managed through safe working practices, 6 such as safe positioning (pads), preparation (clothing) and other adjuncts to encourage natural cooling of the body (bore fan, controlled ambient temperature).…”

Section: Investigationsmentioning

confidence: 99%

Heattech clothing technology and potential for thermal injury in MRI

Hudson¹,

Abrantes²

2023

BJR|case reports

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A patient attended for an MRI scan wearing Heattech thermal clothing. Following the scan, the patient experienced a heating and sunburn sensation over their back. Further investigation has highlighted one similar event to this internationally due to the clothing technology used. The intention of this report is to raise awareness of the potential for this clothing technology to cause thermal injury when worn within MRI, as well as to further emphasise the importance of assessing patient clothing prior to scanning.

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Section: Investigationsmentioning

confidence: 99%

Heattech clothing technology and potential for thermal injury in MRI

Hudson¹,

Abrantes²

2023

BJR|case reports

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“… 18 Based on the analyzed MRI safety reports, referral of contraindicated devices (32% of reports) and a failure to verify safety (21.5%) were identified as the two main trends. 19 A Swedish study found that incidents involving MRIs are commonly underreported. 20 MRI accidents can be minimized by implementing strict guidelines, effective management, and establishing MRI safety policies.…”

Section: Introductionmentioning

confidence: 99%

MRI Safety Practice Observations in MRI Facilities Within the Kingdom of Jordan, Compared to the 2020 Manual on MR Safety of the American College of Radiology

Ayasrah¹

2022

MDER

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Purpose The absence of ionizing radiation in MRI applications does not guarantee absolute safety. Implementing of safety guidelines can ensure high-quality practice in the clinical MRI with the minimum risk. For this purpose, this cross-section quantitative study conducted in Jordan Kingdom aimed to assess current MRI safety guidelines in comparison with those of 2020 Manual on MR Safety of the American College of Radiology (ACR). Patients and Methods A site observation study of 38 MRI units was undertaken in June 2021. A well-structured MRI safety questionnaire was the primary data collection method. Data were subjected to a descriptive statistics content analysis by the SPSS version 20. The results were analyzed to yield comprehensive discussions. Results A total of 38 MRI facilities in participated in this study with the responding rate of 44.7%. Patient screening areas and changing rooms were available in about 29% (11/38) of the MRI facilities. Most facilities (55%, 21/38) conducted verbal screening only whereas 21% implemented both written and verbal screening for their patients and companions in zone II, which was present in a percentage of 29% in the approached facilities. Meanwhile, only 13 (43.2%) of 38 facilities used handheld magnets for physical screening, 25 (65.8%) of MRI units did not use any kind of ferromagnetic metal detection systems. Three (7.9%) participating centers had MR-safe wheelchairs, ventilators, anesthesia machines, and stretchers. Most MRI facilities participating in this study (71%) had emergency preparedness plans for alternative power outages. Despite a relatively low number of participating centers having an emergency exit or code (26.3% and 10.5%, respectively), none of them performed practice drills for such scenarios. Conclusion Investing in new MR-safe equipment requires introducing ferromagnetic detecting systems. More research is needed to establish the degree of MRI professional’s safety-related education.

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“…Westbrook and Talbot measured radiographers' knowledge about MR, and they found that MR safety knowledge in particular was very low [11]. Hudson et al also pointed out that the low level of MR safety knowledge of radiographers could cause incidents [12].…”

Section: Introductionmentioning

confidence: 99%

Magnetic resonance imaging incidents are severely underreported: a finding in a multicentre interview survey

et al. 2021

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Objectives The purpose of this study was to develop a procedure to investigate the occurrence, character and causes of magnetic resonance (MR) imaging incidents. Methods A semi-structured questionnaire was developed containing details such as safety zones, examination complexity, staff MR knowledge, staff categories, and implementation of EU directive 2013/35. We focused on formally reported incidents that had occurred during 2014–2019, and unreported incidents during one year. Thirteen clinical MR units were visited, and the managing radiographer was interviewed. Open questions were analysed using conventionally adopted content analysis. Results Thirty-seven written reports for 5 years and an additional 12 oral reports for 1 year were analysed. Only 38% of the incidents were reported formally. Some of these incidents were catastrophic. Negative correlations were observed between the number of annual incidents (per scanner) and staff MR knowledge (Spearman’s rho − 0.41, p < 0.05) as well as the number of MR physicists per scanner (− 0.48, p < 0.05). It was notable that only half of the sites had implemented the EU directive. Quotes like ‘Burns are to be expected in MR’ and not even knowing the name of the incident reporting system suggested an inadequate safety culture. Finally, there was a desire among staff for MR safety education. Conclusions MR-related incidents were greatly underreported, and some incidents could have had catastrophic outcomes. There is a great desire among radiographers to enhance the safety culture, but to achieve this, much more accessible education is required, as well as focused involvement of the management of the operations. Key Points • Only one in three magnetic resonance–related incidents were reported. • Several magnetic resonance incidents could have led to catastrophic consequences. • Much increased knowledge about magnetic resonance safety is needed by radiologists and radiographers.

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A 3-year review of MRI safety incidents within a UK independent sector provider of diagnostic services

Cited by 8 publications

References 20 publications

Heattech clothing technology and potential for thermal injury in MRI

Heattech clothing technology and potential for thermal injury in MRI

MRI Safety Practice Observations in MRI Facilities Within the Kingdom of Jordan, Compared to the 2020 Manual on MR Safety of the American College of Radiology

Magnetic resonance imaging incidents are severely underreported: a finding in a multicentre interview survey

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