MRI safety survey finds two-thirds of incidents go unreported

By Edna Astbury-Ward, PhD, contributing writer

July 28, 2021 -- A new study from Sweden has shown that MRI-related incidents tend to be greatly underreported. The authors warn that some unreported incidents may have catastrophic outcomes, and a major educational effort is urgently required.

"To enhance the safety culture across all sites, more easily accessible education is needed," the authors wrote in an article published by European Radiology on 20 July. "Broadening collaboration among radiographers, radiologists, and MR physicists will also enhance the safety work."

The researchers, led by Johan Kihlberg, PhD, a specialist radiographer at the Center for Medical Image Science and Visualization (CMIV) in Linköping, interviewed the managing radiographer at 13 sites across Sweden about the level of MR safety and MR-related incidents. They used a semistructured questionnaire covering aspects such as safety zones, examination complexity, staff MR knowledge, staff categories, and implementation of EU directive 2013/35.

The group focused on formally reported incidents that had occurred during 2014-2019, and unreported incidents during one year. Open questions were analyzed using conventionally adopted content analysis. Thirty-seven written reports for five years and an additional 12 oral reports for one year were analyzed. Only 38% of the incidents were reported formally, suggesting that about 100 incidents remained unreported.

Examples of MRI accidents
Examples of MRI accidents. (A) A trolley is stuck on the magnet. (B) A patient monitor is stuck on the magnet. (C) A patient experienced a blister in the groin. (D) Safety zone II is missing (the red lines represent the three doors to the unit). Images courtesy of Johan Kihlberg, PhD, and colleagues and European Radiology.

About 7% of incidents were reported as radiofrequency (RF) burns. Attitudes such as "burns are to be expected once in a while," which imply that responders felt it was unnecessary to report such incidents, suggest that some of the missing reports could have been RF burns.

According to the investigators, "The willingness to report incidents varied widely across the sites. One site routinely reported scanned patients that later were found to have coins or paper clips in their clothing. This reflects an accurate interpretation of Swedish law that defines incidents as 'Unwanted events that happened, or could have happened.' "

Some sites did not report any unwanted events at all during the five years -- something that may not be correct, and this could be an additional reason for the underreporting.

Almost half of the responders were unaware of the EU directive 2013/35, which was adopted into the occupational health law in Sweden in 2016 (see figure below).

Implementation of EU directive
Implementation of EU directive. The responders were asked which year the Swedish law AFS 2016:3 (implementation of the EU directive 2013/35) was implemented. Courtesy of Johan Kihlberg, PhD, and colleagues and European Radiology.

The authors identified a continued need and wish for additional and more easily available MR safety education for all professionals working with MRI. They suggested the guarantor could be either a national agency or a nonprofit association, and they urged hospital managers to prioritize the issue.

"MR-specialized radiographers have a very diverse background, and not surprisingly, MR knowledge varied substantially across the sites," they noted. "The entire process of maintaining MR safety requires collaboration between different professions such as radiographers, MR physicists, and radiologists."

Other key findings

In the study, MRI knowledge increased as a consequence of the availability of MR physicists at the site, and that appeared to decrease the risk for incidents. Also, almost all radiographers were concerned about their radiologists' MR safety knowledge.

"We speculate that the division of work tasks might not be sufficiently well defined, so when several staff are working together, the MR safety is not fully covered, but when working alone, you are 'the last man standing,' " the authors wrote.

"However, the more people who check the MR safety, the better it will be. International guidelines state that to be able to handle emergencies and to maintain MR safety at the site, there should be two staff members at a site with a single scanner and at least three staff members in a dual scanner unit," they added.

A lack of adequate warning signs can be one problem
Lack of adequate warning signs in MRI scanning rooms can be a problem. To address this, the Institute of Physics and Engineering in Medicine (IPEM) has produced a set of MRI safety notices for free download from its website.

Staff at some sites said they cleaned the MR unit themselves, while other sites reported using external janitors, but they never left these workers unsupervised. The safety due to cleaning appeared to be high, and external janitors did not seem to affect MR safety in a negative way.

The main limitation of this study is the relatively limited number of formally documented incidents, and this resulted in relatively weak, but significant, correlations, the authors wrote.

The plan now is to repeat this survey every three to five years, perhaps expanding it to also include MR safety knowledge and attitudes among radiologists and physicists.

Copyright © 2021

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