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Publication Type: Sentinel Event Alert
Single or Multiple Incident: Multiple
Date: 2/1/2008 12:00:00 AM
"While the capabilities of the MRI scanner are well-recognized, its inherent dangers may not be as well known. Patients have sustained a variety of injuries during the MRI scanning process, including death. The most common patient injuries are burns from wires and leads. This alert describes actions to reduce risk."


Environment / Equipment
  1. Only use equipment that has been tested and approved for use during MRI scans.
Rules / Policies / Procedures
  1. Restrict access to all MRI sites by implementing the four zone concept as defined in the ACR Guidance Document for Safe MR Practices.
  2. Provide all MRI patients with hearing protection.
  3. "Have a specially trained staff person who is knowledgeable about the MRI environment accompany any patients, visitors and other staff who are not familiar with the MRI environment inside the MRI suite at all times."
  4. "Use trained personnel to screen all non-emergent patients twice, providing two separate opportunities for them to answer questions about any metal objects they may have on them, any implanted devices, drug delivery patches, tattoos, and any electrically, magnetically, or mechanically activated devices they may have."
  5. Never attempt to run a cardio-pulmonary arrest code or resuscitation within the MR magnet room itself.
  6. Take precautions to prevent patient burns during scanning.
  7. Ensure that the MRI technologist has the patient's complete and accurate medical history to ensure that the patient can be safely scanned.
  8. Proactively plan for managing critically ill patients who require physiologic monitoring and continuous infusion of life sustaining drugs while in the MRI suite.
Training
  1. "Annually, provide all medical and ancillary staff who may be expected to accompany patients to the MRI suite with safety education about the MRI environment and provide all staff and patients and their families with appropriate materials that explain the potential for accidents and adverse events in the MRI environment."

Preventing accidents and injuries in the MRI suite