Systemic problems led to MRI accident
Here are some of the systemic problems identified by Westchester Medical Center in Valhalla, NY, and the corrective actions the hospital took:
• Inadequate oxygen supply in the MRI room.
The system in place related to the delivery of oxygen safely to the patients during performance of MRI was not effective. 2-H cylinders secured to the wall in the computer room were the source for oxygen for patients during MRI scanning.
Action: Remove the H cylinders as the oxygen source for patients during MRI. Only nonferrous oxygen cylinders will be used for those patients requiring oxygen during scan. Currently, the patients requiring oxygen will be met at the entrance of the MRI unit by MRI personnel who will transfer the patient from the regular hospital cylinder to a nonferrous aluminum cylinder and escort patient into MRI suite. For outpatients who bring their own tanks, this unit will be stored in the patient’s automobile during the procedure. When the patient’s study has been completed, the patient will be switched from MRI-compatible tank to either a hospital cylinder or to the patient’s own tank outside the MRI area.
•Oxygen supplies could be insufficient during an MRI, requiring a resupply.
There was a flowmeter in the MRI room and the practice was to change the H cylinder when it was at or below 500 pounds per square inch (psi). When the patient in question first entered the MRI room, the flowmeter was turned on and indicated oxygen flow. Immediately before the scanning was begun, the anesthesiologist attempted to increase the flow without success.
Action: The source for patients requiring oxygen during an MRI scan will be exclusively nonferrous cylinders. A full nonferrous E cylinder will be provided for each patient. It will be the responsibility of the MRI technologist/RNs to ensure a full cylinder is provided per patient. MRI personnel will monitor pressure readings of the tank in use every 15 minutes; if the reading reaches 500 psi, the tank will be replaced with a full cylinder.
• There was no written policy regarding oxygen in the MRI suite.
The department of radiology had written policies/procedures related to MRI scanning and safety, but there was no written policy related specifically to the provision of oxygen during the MRI scan.
Action: Written policy/procedure to include training of responsible personnel will be developed. The respiratory therapy department will communicate the written policy and associate training to involved staff. Documentation of training and ongoing competency will be maintained. This will include current staff and new staff members as part of general orientation to the MRI milieu.
• With no written policy or education on oxygen use in the MRI suite, the procedure followed was not consistent.
Staff were not trained specifically in how to provide oxygen during an MRI, and staff members had different habits.
Action: Development of written policies/procedures related to training and education of appropriate staff and ongoing competencies will be maintained.
Human resources problems also
• No written procedure existed for management of oxygen delivery sources for patient undergoing MRI studies. Competencies have not been developed.
Action: Upon completion of policy/procedure and appropriate training, competencies will be developed and assessed according to organizational policy.
• MRI orientation and inservice training did not include adequate or effective methods to maintain a safe level of awareness on an ongoing basis.
Action: Development of an orientation and inservice program for all staff who enter this area including but not limited to staff, visitors, contracted services. Develop methods to address maintenance of an ongoing safe level of awareness related to the MRI.
• The physical environment was not appropriate for the processes/treatment being carried out.
When the oxygen source for a patient in the MRI room was not adequate, an attempt was made to provide supplemental oxygen. A ferrous oxygen E canister was introduced into the magnetic field. The patient care area adjacent to the MRI Scanner was not treated as a restricted magnetic field area.
Action: The restricted magnetic field area around the magnet should be expanded to include the alcove or patient care area. Non-compatible MRI equipment (such as oxygen tanks, pulse oximeters, ventilators, stretchers, and fire extinguishers) where available will be utilized. Utilize additional signage and physical markings to identify and secure area. Reinforce policy and procedures for screening all who enter the secure area and include use of screening tool. Develop screening tools that give consideration to methods and limitation in vision, fluency, language, and literacy.
• Policies exist to address specific risks but a comprehensive risk assessment process was not in place.
Action: An outside expert will conduct an environmental MRI risk assessment.
• Other items were found to be dangerous.
The fire extinguishers adjacent to the MRI scanner were ferro-magnetic. A code cart with ferro-magnetic materials was in the patient care area adjacent to the MRI scanner.
Action: Replace with MRI-compatible fire extinguishers. Revise and review policies/procedures, emergency for cardiac and respiratory events including delineation of responsibilities. Assure appropriate staffs are trained accordingly. Door to console room has been removed to minimize obstacles in technologist response to patient care needs (or staff). A plastic, breakaway chain has been placed across the scan room as a visual reminder that this is a restricted area. Code cart has been relocated to safe area.
• Controllable equipment factors did contribute to the event.
H cylinders were used as oxygen source for patients. Ferrous materials were in an area adjacent to the magnet and were easily accessible to restricted magnetic field.
Action: Only MRI-compatible oxygen cylinders will be permitted anywhere in the MRI suite. The restricted field area surrounding the magnet was revised to include the alcove or patient area.
• Necessary information was not available when investigating the incident.
No clock in the MRI room to provide accurate documentation of timing.
Action: An MRI-compatible clock was installed.
• Communication among participants was not effective.
Communication between a person other that the patient in the MRI room during the scan is achieved by that individual knocking on the window between the MRI and console room to attract the attention of the MRI technologist performing the scan.
Action: Evaluate MRI-compatible communication enhancements.