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Set policy to comply with MRI safety requirements

Radiology Administrator's Compliance and Reimbursement Insider, May 1, 2008

To ensure that your MRI suite operates safely, your facility should develop a policy to reflect the recommendations of your safety audit. The following policy is based on recommendations from The Joint Commission (formerly JCAHO) and is reprinted with permission. Review your policy with your attorney and safety auditor.

MRI safety policy

The facility shall follow the Joint Commission recommendations for reducing MRI accidents and injuries:

1. Restricted access. Access is restricted to all MRI sites, pursuant to the four-zone concept as defined in the American College of Radiology Guidance Document for Safe MR Practices: 2007. The four-zone concept restricts access to the MRI scanner according to the following zones:

Zone I: General public

Zone II: Unscreened MRI patients

Zone III: Screened MRI patients and personnel

Zone IV: Screened MRI patients under constant direct supervision of trained MRI personnel

2. Patient screening. Trained personnel shall screen all nonemergent patients twice to provide separate opportunities for them to answer questions about the following items they may have on them:

• Metal objects
• Implanted devices
• Drug delivery patches
• Tattoos
• Electrically, magnetically, or mechanically activated devices

If the patient is unconscious or unable to answer questions, staff members must question the patient’s family member or surrogate decision-maker. If this person is unsure, staff members must use other means to determine whether the patient has implants or other devices that could be negatively affected by the MRI scanner (e.g., looking for scars or deformities, using plain-film radiography or ferromagnetic detectors to assist in the screening process, etc.)

3. Patient medical history. The MRI technologist shall review the patient’s complete and accurate medical history to ensure that the patient can be safely scanned. The technologist must check all implants against product labeling or manufacturer literature specific to that implant or peer-reviewed published data regarding the device or implant in question. The director of radiology shall ensure that the technologist has ready access to this information.

4. Patient assistance. A specially trained staff person who is knowledgeable about the MRI environment shall accompany any patients, visitors, and other staff members who are not familiar with the MRI environment inside the MRI suite at all times.

5. Safety education. Annually, provide safety education to all medical and ancillary staff members who may be expected to accompany patients to the MRI suite and provide all staff members and patients and their families with appropriate materials (e.g., guidelines, brochures, posters) that explain the potential for accidents and adverse events in the MRI environment.

6. Burn precautions. Staff members shall take the following precautions to prevent patient burns:

Ensure that no items (such as leads) are formed into a loop since magnetic induction can occur and cause burns

If the patient’s body touches the bore of the MRI scanner, use nonconductive foam padding to insulate the patient’s skin and tissues

Place a cold compress or ice pack on EKG leads, surgical staples, and tattoos that will be exposed to radiofrequency irradiation during the MRI process

7. Equipment safety. Staff members shall only use equipment (e.g., fire extinguishers, oxygen tanks, physiologic monitors, and aneurysm clips) tested and approved for use during MRI scans.

8. Critically ill patients. Staff members must plan for managing critically ill patients who require physiologic monitoring and continuous infusion of life-sustaining drugs while they are in the MRI suite. Never attempt to run a cardiopulmonary arrest code or resuscitation within the MRI magnet room itself.

9. Ear plugs. Provide all MRI patients with ear plugs.

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