by John R. Fischer
, Senior Reporter | December 27, 2018
More than a quarter of MR screening events – scenarios with the potential for setting off adverse events – are caused by the presence of external and internal objects or devices inside the scanner room.
That’s the finding made by the Pennsylvania Patient Safety Authority which identified more than 1,100 such events submitted to the Pennsylvania Patient Safety Reporting System between 2009 and 2017.
“With the advancement of medical technology, the number of patients with external or internal medical devices is increasing, and care within the MR environment is changing,” Cynthia Field, senior patient safety analyst for the Pennsylvania Patient Safety Authority, told HCB News. “More complex procedures are being done with MR guidance, often requiring more equipment to support the patient. These changes increase the potential risk for ferromagnetic devices entering the MR suite and highlight the need for continued awareness and focus on MR screening.”
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Screening events refer to scenarios in which patients were not harmed during scans despite the presence of risk factors, such as ferromagnetic devices, in the MR system. Such events signify a lack of understanding of the potential risks and protocols necessary for safety during exams.
In their initial assessment, researchers identified 1,448 events that consisted of errors related to the procedure/treatment/test, but excluded 340 related to factors such as adverse reactions to contrast; wrong site and scheduling issues; exams outside of MR; changes in patient’s clinical status; intravenous infiltrations and extravasations; incorrect results; patient injury caused by unintended physical contact with MR equipment; and the inability to complete a study due to specific patient factors.
Of the remaining 1,108 events identified, 607 involved the presence of internal medical devices, the most common of which were pacemakers at 353, while 187 were due to external solutions. One hundred and one events involved internal non-medical objects such as metal artifacts or tattoos, and 198 were external non-medical objects.
More than one-third of events involved external objects that were carried in by or attached to the patient or healthcare staff. Even wearing certain forms of yoga pants
can be dangerous due to the presence of metallic materials embedded within the garments.
As a result of these and internal-related screening events, experts have called for a better job in educating radiologists, rad techs and MR techs
in how to identify and address potential risks faster, whether they have to do with the system or a particular item. They also have asked for proper screening technologies to be put in place, such as ferromagnetic detectors.