Sentinel Event Alert highlights MRI-related injuries
Accreditation Connection, February 15, 2008
The Joint Commission issued this week its most recent Sentinel Event Alert, "Preventing accidents and injuries in the MRI suite."
More than 10 million magnetic resonance imaging (MRI) scans are conducted in the U.S. every year. Five incidents relayed to the Joint Commission's Sentinel Event database resulted in four patient deaths. These incidents were caused by:
- a projectile
- cardiac events (three separate incidents)
- a misread scan, causing delay of treatment
A 2005 study by medical physicist Jason Launders, MSc, of the ECRI Institute, found that over a 10-year span there were 389 MRI-related events reported to the Food and Drug Administration's (FDA) Manufacturer and User Facility Device Experience Database. This included pacemaker and insulin pump failures, burns (70% of reported incidents), and projectiles (10% of reported incidents).
Burns are frequently caused by wires and leads growing too hot, while projectiles are due to the fact that magnets in the MRI scanner are constantly active, making the risk of projectiles drawn to the magnets (e.g., pens, tools, cleaning equipment) a constant danger.
Additional information can be found on the Joint Commission's Web site here.
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