Joint Commission alerts industry on MRI accident, injury prevention

The Joint Commission (JC) has issued a Sentinel Event Alert that urges hospitals and ambulatory care centers to pay special attention to preventing accidents and injuries that can occur during MRI scans.

More than 10 million MRI scans are performed each year in the United States and the Sentinel Event Alert brings the reality of risks associated with MRIs to the attention of accredited U.S. healthcare organizations, offering practical solutions to avoiding injuries or deaths, according to the JC.

“MRI technology represents an important advance in diagnostic medicine, but special care must be taken to protect patients,” said Mark R. Chassin, MD, MPP, MPH, president, JC. “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. This Alert offers healthcare organizations specific steps that can be taken to keep patients safe.” 

According to the Alert, the FDA has received nearly 400 reports of MRI-related accidents over the past decade. More than 70 percent of accidents were burns, while 10 percent of injuries occurred when metal objects such as ink pens, cleaning equipment and oxygen canisters have become “missiles” when pulled into the magnetic field of the scanner.

To reduce the risk for MRI injuries to patients, The JC’s Alert recommends that healthcare organizations take the following steps:

• Restrict access to all MRI sites by creating safe zones recommended by the ACR;
• Use trained screeners to perform double checks of patients for items such as metal objects, implanted or other devices, drug delivery patches and tattoos;
• Ensure that the MRI technologist has the patient’s complete and accurate medical history to ensure that the patient can be safely scanned;
• Have a specially trained staff person accompany any patients, visitors and staff into the MRI suite at all times;
• Annually educate all medical and ancillary staff who may accompany patients into the MRI suite about the risk of accidents;
• Take precautions to prevent patient burns during scanning;
• Only use fire extinguishers, oxygen tanks and other equipment that have been tested and approved for use during MRI scans (equipment that will not be attracted to the magnet);
• Manage critically ill patients who require monitoring and life-sustaining drugs to assure that their care needs are continuously met while in the MRI suite;
• Provide all MRI patients with ear plugs to diminish the loud “knocking” noise emanating from the equipment; and
• Never run a cardio-pulmonary arrest code or resuscitate a patient in the MRI room.

The warning about risks associated with MRIs is part of a series of Alerts issued by the JC. The complete list and text of past issues of Sentinel Event Alert can be found on the JC’s website.