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Recent MRI Accident Emphasizes Concerning Trend |
New details have emerged regarding a mysterious yet, allegedly, serious accident involving a nurse in an MRI suite in a Northern California hospital. The accident happened on February 23, and it has since been revealed that it occurred at Kaiser Permanente’s Redwood City Medical Center, according to a statement the company released to Tobias Gilk, MRSO, MRSE, senior VP of RAD-Planning and founder of Gilk Radiology Consultants.
Although the statement provided to Gilk, who is an expert on MRI safety, does clarify the location of the incident and that it did involve a patient, it stopped short of sharing additional details due to HIPAA restrictions and an ongoing investigation of the ordeal.
Details of the incident are unclear. It has been speculated that the accident involved a nurse transporting a patient to an MRI suite on a gurney, which was allegedly sucked into the MRI bore, causing the patient to fall off of the stretcher and the nurse to sustain serious injuries. According to reports, the senior MRI tech on duty during that time was not in the room when the nurse was transporting the patient.
Story Courtesy of Hannah Murphy - Innovate Healthcare
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American College of Radiology Recommends the Use of a Caution Barrier and Procedural "Timeouts" at the Entrance to the MRI Room |
The magnetic field generated by today’s clinical MRI’s typically range from 30,000 to 60,000 and even up to 140,000 times the strength of Earth’s magnetic field. These incredibly powerful attractive forces can not be turned on and off, meaning these uniquely dangerous conditions are omnipresent within the MRI Suite – 24 hours a day, 365 days a year. It is imperative that the safety solutions utilized to prevent unscreened or inadvertent access to the MRI suite operate ALL the time and are NOT reliant on individual, manual operation.
The TechGate Auto rotates into position AUTOMATICALLY providing the required lighted warning signage and physical barrier across the opening to the MRI suite - dramatically mitigating the risk of projectile accidents. Alternatively, plastic chains and retractable belts require manual clipping and unclipping meaning they are never consistently utilized and do not adequately communicate the risks or conditions within the MRI suite.
The TechGate Auto MRI caution barrier has become the trusted solution for MRI room access management – “Safety isn't up for debate – Get YOUR TechGate.”
TechGate Auto - It Just Makes Sense!
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Ferromagnetic Detection at the MRI Doorway Is Too Late - Automated Caution Barrier Is the Effective Solution
ACR MRI Safety Committee – White Paper on MRI Safety 2020 Pertaining to the Use of Ferromagnetic Detection and MRI Entrance Caution Barriers
Caution Barrier = Zone 4
FMD = Zone 3
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The recently promulgated ACR White Paper on MRI Safety 2020 embody the consensus recommendations for MRI best safe practices and form the foundation for individual, site – specific protocol establishment. As these recommendations have been established by an esteemed committee of MRI safety professionals and create a framework of guidance for ACR accreditation, the consistent application of these recommendations by the industry coalesce into a widely recognized and accepted standard of care. The recommendations include several provisions related to screening individuals entering the MRI area and, more specifically, the application of Ferromagnetic Detection Systems and warning signage. These provisions essentially recommend the use of detection devices that can differentiate between ferrous and non-ferrous objects and the recommended location of screening utilizing these devices is prior to individuals entering Zone 3 (as outlined in the operational schematic from the guidance document). Additionally, the ACR committee recommends adoption of a “timeout” protocol prior to anyone entering Zone 4 and the utilization of “caution barriers” and illuminated warning signage that the “magnet is always on.” Utilization of the TechGate Auto Caution Barrier solution addresses all these Zone 4 access control recommendations. Below are the pertinent sections referenced in the 2020 ACR MR Safety Manual along with page references.
The full ACR Safety Manual can be accessed via the web link here.
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Important Updates to the American College of Radiology MR Safety Manual Draft Now Available For Public Comment |
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Latest Zone 3 Podcast Interview on Hybrid MRI Environments and their Safety Challenges with Craig DeVincent and Christina Calvin of UCSF
Zone3Podcast is always happy to welcome anyone who is considered a specialist in their area of expertise. This is no exception as both David Devincent R.T.(MR)(MRSO)(R)(CT) and Christina Calvin R.T.(MR)(MRS)(R)(M)(CT) of the University of California San Francisco visit the studio to discuss the concept of hybrid environments as it pertains to clinical applications, safety considerations, and architectural design.
Craig is originally from Pittsburgh, Pa where he was lucky to have worked directly with Dr. Emanuel Kanal. Currently, he’s been with UCSF for 18 years with 16 of those years being in leadership. Christina has spent a large majority of her life in California. Originally starting her career in Radiography. Her current role is MRI safety officer for all sites of UCSF Medical Center. She oversees the implementation of hybrid MRI environments. Her Position is generally defined as using MRI within an atypical setting to assess the anatomy, function or molecular biological conditions of the patient/research subject.
As Magnetic Resonance Imaging continues to grow. So do its applications integrated throughout the healthcare facility.
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LATEST DOTMED MRI SAFETY ARTICLE : New Solutions, Better Training and Regulation for Reducing MR Adverse Events |
DotMed has recently issued an MR safety article in their September edition of Healthcare Business News Magazine by Lauren Dubinsky, Senior reporter.
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The MOST Versatile MRI Handheld Screening Devices Available - Address the Two Biggest Risks in MRI Safety : Burns and Projectiles |
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- Two Solutions in a Single Device
- Silent Mode Reduces Audible Alarm Fatigue
- Easy To Use - When You Need It
- Addresses ACR, Joint Commission, FGI recommendations / requirements for the siting of FMD
- Thousands of Units Deployed and Used Daily
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Recent TechGate Auto Deployment on a New Magnet - Opportunity to Implement Enhanced Safety Procedures |
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MRI Safety Does Not Improve on Its Own - Changes Are Required |
A few quick points to help guide action:
- A near miss is not a lucky break but rather a symptom of a flawed process that requires correction
- Safety measures that aren't providing value are wasted efforts - illusions of safety don't prevent adverse events
- Make the right thing to do the easy thing to do and it will get done every time
- Get off on the right foot, new scanners or upgrades offer the chance to implement new safety measures from the start
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MRI Safety Posters - FREE Downloadable MRI Safety Posters made available by the FDA |
In partnership with the Society for Magnetic Resonance Technologists (SMRT), the FDA has developed a series of posters addressing MRI safety key aspects for MR technologists and other site personnel.
The MRI Burn Prevention poster provides tips for preventing patient burns, the most common MRI related adverse event.
The two other posters address safety issues that arise when medical devices are used in the MR environment. One poster gives tips for scanning patients with implants, and the other poster provides information about how to interpret MRI safety labeling.
All three posters are available for free download below.
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Recent TechGate Auto Deployment address Line of Sight and Common Corridor Issues |
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TechGate Auto - Caution Barrier : Solving MRI Zoning and Line of Sight Issues |
Common access corridors adjacent to the MRI room, mixed modalities sharing the same control room or changing areas and lack of direct line of sight from the control room to the MRI entrance highlight MRI safety concerns.
A significant change the 2019 ACR White Paper on MR Safety has implemented is the recommendation for the use of a physical barrier to the MRI room when the door to the MRI room is open. The specific language reads:
“ZONE IV. The entry door to Zone IV (MR system room) should be closed except when it must be open for patient care or room/MR system maintenance. During the times that the door to the MR system room must remain open, a "caution" barrier is recommended at the entry to Zone IV to inhibit unintended passage of personnel and/or materials from Zone III to IV. "
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Aegys, LLC
Lemont, IL
Made in the USA
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