Planning an MR suite: What can be done to enhance safety?

Gilk, Tobias; Kanal, Emanuel

doi:10.1002/jmri.24794

Cited by 10 publications

(9 citation statements)

References 2 publications

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“…While MRI began as a purely diagnostic imaging modality, in recent years, MR technology has expanded into additional areas, such as guiding interventional procedures and planning and gating radiation therapy. Because MRI does not use ionizing radiation, it can be perceived as a completely safe imaging modality by those unfamiliar with the hazards of the MR environment . Known hazards in the MR environment include a strong static magnetic field, pulsed gradient magnetic fields, and radiofrequency energy .…”

Section: Introductionmentioning

confidence: 99%

“…Because MRI does not use ionizing radiation, it can be perceived as a completely safe imaging modality by those unfamiliar with the hazards of the MR environment. 1 Known hazards in the MR environment include a strong static magnetic field, pulsed gradient magnetic fields, and radiofrequency energy. [2][3][4] The strong, static magnetic field attracts magnetic objects that may become projectiles.…”

Section: Introductionmentioning

confidence: 99%

“…Potential harms in the MR environment include injury to patients, medical professionals, or laypeople due to projectile events or unexpected device motion due to the static magnetic field, tinnitus, or hearing loss (temporary or permanent) due to acoustic noise, peripheral nerve stimulation, heating and/or patient burns from the radiofrequency energy, and crush and pinch injuries from moving parts and falls. 1,2,5 Misdiagnosis or delayed treatment from distorted or incorrect images is also possible. 5 The purpose of this article was to provide an overview of 10 yr (2008-2017) of FDA adverse event reports for MR systems.…”

Section: Introductionmentioning

confidence: 99%

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MRI‐related FDA adverse event reports: A 10‐yr review

et al. 2019

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Purpose To provide an overview of the types of adverse events reported to the US Food and Drug Administration (US FDA) for magnetic resonance (MR) systems over a 10‐yr period. Methods Two reviewers independently reviewed adverse events reported to FDA for MR systems from 1 January 2008 to 31 December 2017 and manually categorized events into eight event types. Thermal events were further subcategorized by probable cause. Objects that became projectiles were also categorized. Results FDA received 1568 adverse event reports for MR systems between 1 January 2008 and 31 December 2017. This analysis included 1548 reports. Thermal events were the most commonly reported serious injury (59% of analyzed reports). Mechanical events — defined as slips, falls, crush injuries, broken bones, and cuts; musculoskeletal injuries from lifting or movement of the device — (11%), projectile events (9%), and acoustic events (6%) were also observed. Conclusions Adverse events related to MR systems consistent with the known hazards of the MR environment continue to be reported to FDA. Increased awareness of the types of adverse events occurring for MR imaging systems is important for prevention.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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MRI‐related FDA adverse event reports: A 10‐yr review

et al. 2019

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“…Sites should have a process for reporting all MRI safety incidents and near misses. Clear delineation of the four zones of MRI safety helps ensure that only MRI-safe personnel and devices enter restricted areas (11). Physical barriers at the entry to zone 4 can impede access to MRI equipment (Fig 1).…”

Section: Sa-cme Learning Objectives Introductionmentioning

confidence: 99%

“…At our institution, consecutive safety events caused primarily by nonradiology staff with MRI access led to a comprehensive review of our MRI safety policies. MRI had often been perceived as the "safe" imaging environment by non-MRI personnel owing to the lack of ionizing radiation and a general unfamiliarity with the full spectrum of MRI safety (11). A multidisciplinary task force was developed, which improved MRI safety by limiting the number of staff with access to MRI, developing new educational modules and training required for MRI access, and empowering MRI staff to fully enforce safety policies.…”

Section: Sa-cme Learning Objectives Introductionmentioning

confidence: 99%

Never Events in Radiology and Strategies to Reduce Preventable Serious Adverse Events

et al. 2018

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The term never event in medicine was originally coined by Kenneth W. Kizer, MD, MPH, former chief executive officer of the National Quality Forum, to describe particularly shocking medical errors that should never occur, such as wrong-site surgery or death associated with introduction of a metallic object into the MRI area. With time, the National Quality Forum's list of never events, or "serious reportable events," has been expanded to include adverse events that are unambiguous, serious, and usually preventable. In this article, the never event framework has been used to describe (a) the errors that may occur in an imaging department that are serious and usually preventable with a review of the causative factors and (b) strategies to eliminate and reduce the adverse effects of these avoidable errors. These errors are often rooted in communication breakdowns and can only be eliminated with a true shift to a culture of open reporting and patient safety. ©

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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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Planning an MR suite: What can be done to enhance safety?

Cited by 10 publications

References 2 publications

MRI‐related FDA adverse event reports: A 10‐yr review

MRI‐related FDA adverse event reports: A 10‐yr review

Never Events in Radiology and Strategies to Reduce Preventable Serious Adverse Events

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

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