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The Joint Commission Highlights MRI Safety with a Sentinel Event Alert

Kristina Woodworth

*Contributing Editor, SciMantis Communications, Inc, Pen Argyl, Pennsylvania.
Address correspondence to: Kristina Woodworth, Contributing Editor, SciMantis Communications, Inc, PO Box 3, Pen Argyl, PA 18072. E-mail: kristina@scimantis.com.

To raise awareness about the potential for accidents during magnetic resonance imaging (MRI) scans, the Joint Commission has issued a Sentinel Event Alert that emphasizes the importance of safety measures in the MRI suite.

More than 10 million MRI scans are performed in the United States each year,1 and MRI is considered to be an important advance in imaging safety. Unlike other diagnostic procedures, such as X rays and computed tomography (CT), MRI does not expose the patient to potentially harmful radiation during the procedure. However, imaging professionals should be aware of the possible safety hazards associated with MRI, especially as more powerful MRI machines are now being introduced.2 "The increasing use of MRI scans as a diagnostic tool, coupled with stronger MRI technology, suggests that the risk of accident and injury may increase," according to Mark R. Chassin, MD, MPP, MPH, President of the Joint Commission.2

The Joint Commission based its safety alert on data collected from its Sentinel Event Database, a voluntary reporting system that tracks serious adverse events in healthcare.1

MRI Burns and Other Hazards from Implanted Ferromagnetic Devices
It is critical that MRI personnel obtain an accurate medical history from the patient so that the risk of considerable injury can be prevented. Patients should be asked if they are aware of any implanted prostheses or devices, and medical personnel should determine whether these objects pose a risk of burns or other adverse events. In patients with implantable wires or leads, MR personnel can protect patients with thermal insulation or cold compresses. Those with skin staples also require cold compresses and proper positioning during the procedure to prevent burns. If there is a risk of the patient's skin making contact with the MRI bore, then proper padding should be used to prevent burns.3

Other issues can increase burn risk in patients undergoing MRI. For example, the pre-MRI interview should determine whether the patient is wearing a drug delivery patch because some contain metallic foil that could result in burns during the MRI process. Patients with extensive or dark tattoos (including tattooed eyeliner) may also be at risk of burns because of the presence of iron oxide in the ink. Cold compresses can be used on the affected areas to reduce the risk of burns.3

The presence of an implanted cardiac pacemaker or implantable cardioverter defibrillator is a relative contraindication for MRI due to the substantial hazards posed when these devices are subjected to a magnetic field. The American College of Radiology (ACR) recommends that in these patients, MRI studies should only be performed on a case-by-case basis in the presence of experienced radiologic and cardiac personnel.3

In considering patients who may be at risk of burns and other adverse effects associated with implanted devices, MR personnel should keep in mind that stronger MR fields increase the risk of adverse effects. For example, a patient with a tattoo who has undergone a 1.5 Tesla scan without burns could still be at risk of burning if he is later subjected to a 3.0 Tesla scan.3

Ferromagnetic Missiles
Although only 1 fatal accident involving a ferromagnetic object becoming a missile in the MRI suite has been reported,2 the Joint Commission has suggested that these events may be more common than most medical personnel realize.2 The report notes that many personnel do not realize that the magnetic field of the MRI is always on, meaning that there is always the potential for accidents due to ferromagnetic objects being brought into the MRI suite.2 This is especially true for maintenance workers and housekeeping staff because these individuals may be unaware of the dangers posed by the magnetic field.2,3 Emergency situations, such as fires or other crises, also can pose important hazards if emergency workers enter the MRI's magnetic field because their equipment is likely to be ferromagnetic. A list of ferromagnetic objects that could potentially become missiles in the MRI suite is provided in the Table.


To reduce the risk of ferromagnetic objects entering the magnetic field, the Joint Commission, as well as the ACR, have recommended creating a secure MRI suite that is only accessible to qualified MR personnel.2,3 Trained personnel should also be responsible for escorting emergency personnel to restricted areas during an emergency.3,4 In the event of a medical emergency, such as cardiac arrest, the ACR recommends performing rescue procedures, such as cardiopulmonary resuscitation, while the patient is being moved from the imaging room.3 The Figure shows a 4-zone MRI suite design recommended by the ACR to restrict the movement of individuals within the areas affected by the magnetic field (Zones III and IV).4


Cryogen Effects
The magnetic field of most MRI systems is in force at all times, and dissipating or quenching this field requires skilled personnel to prevent or control the escape of cryogenic gases from the instrument. Cryogen liquids, typically helium or nitrogen, are present in MRI devices to cool the magnet. Although these liquids are safe while contained in the instrument, the accidental or deliberate exposure of these liquids to the air results in the immediate boiling to a gaseous state, which can result in catastrophic consequences. Most systems have a venting system that releases these gases to the ambient air, usually through the roof, in the event that quenching is required. The release of cryogenic gases to the MRI suite could result in frostbite-type burns due to the extremely low temperature of these liquids, asphyxiation due to a replacement of oxygenated air with the cryogenic gases, fire hazards, or a hyperbaric pressure environment.3 To reduce the risks posed by the unlikely escape of cryogenic gases, the ACR recommends the inclusion of an emergency exhaust system, in addition to measures to provide passive pressure relief in the event of an accident, within Zone IV of the MRI facility.3

Proper Staff Training Can Make a Difference
The Joint Commission emphasizes the role of MR personnel in ensuring the safety of patients who require MRI. Ideally, patients should be screened twice by separate MR personnel to determine the presence of possible risks, including implanted devices, drug delivery patches, or tattoos. The Joint Commission also recommends that a specialized, trained staff person accompany all patients, visitors, and untrained personnel to restricted areas of the MRI facility at all times. All medical and ancillary MR staff members should also undergo annual safety training that emphasizes the risks associated with the MR environment, according to the Joint Commission.2

The medical community has been supportive of the efforts by the Joint Commission to highlight these critical safety issues, according to a spokesman with the Commission. With the proper staff training and safety measures in place, MRI facilities can effectively reduce the risk of accidents associated with MRI, which is still a remarkably safe and effective imaging modality.

Additional Resources
Those interested in additional information about the Joint Commission Sentinel Event Alert or MRI safety are encouraged to access the following resources:

  The Joint Commission Sentinel Event Alert: Preventing Accidents and Injuries in the MRI Suite

  American College of Radiology (ACR) Guidance Document for Safe MR Practices: 2007

1. The Joint Commission. Joint Commission Alert Shines Light on Preventing MRI Accidents, Injuries. Available at: http://www.jointcommission.org/NewsRoom/NewsReleases/nr_02_15_08.htm. Accessed June 27, 2008.

2. The Joint Commission. Sentinel Event Alert. Preventing Accidents and Injuries in the MRI suite. Available at: http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_38.htm. Accessed June 27, 2008.

3. American College of Radiology (ACR). ACR Guidance Document for Safe MR Practices: 2007. Available at: http://www.acr.org/SecondaryMainMenuCategories/quality_safety/MRSafety/safe_mr07.aspx. Accessed June 27, 2008.

4. American College of Radiology (ACR). ACR White Paper on Magnetic Resonance (MR) Safety Combined Papers of 2002 and 2004. Available at: http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/WhitePaperonMRSafetyCombinedPapersof2002and2004Doc11.aspx. Accessed June 30, 2008.


What did you think of this article?
The Joint Commission Highlights MRI Safety with a Sentinel Event Alert

» Comment From: hlaymaan » Posted on: 07/15/2008 21:31 PM
Excellent article. With recent increase of Tatoos we keep ice packs in refrigerator near MRI.
» Comment From: pgaurin » Posted on: 07/17/2008 13:43 PM
very informative
» Comment From: molly1983 » Posted on: 07/23/2008 11:18 AM
There are 5 total comments: View All Comments

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