Outdated manuals pose MRI safety risks for patients with medical implants

Incomplete or inaccurate safety information related to electronic implants can put patients at serious risk during MRI exams. New research suggests that such a lack of proper safety information may be common. 

Experts from Mayo Clinic in Phoenix, Arizona, recently detailed their organization’s pre-scan safety protocols in place for MRI exams. After reviewing three years of data from their clinic, the team discovered that issues with data integrity—relating to items such as hearing assistance devices and infusion pumps—frequently put patients at risk. 

The group wrote about their experience in Current Problems in Diagnostic Radiology. 

“MR Safety is a growing problem for all radiology (and some nonradiology) practices because the number of patients with implants and needing MRI is growing rapidly,” corresponding author William F. Sensakovic, PhD, and co-authors noted. “Data is needed to determine where typical MR safety workflows are insufficient.” 

Patients with active implants are at greater risk than those with inactive implants or leads because they have an active power source. The magnetic force of MRI scanners could affect the function of these implants, causing them to either malfunction or disable entirely. For patients with active implants, radiology staff must review vendor-defined scan requirements for each specific device and confirm that the necessary parameters are feasible on their department’s equipment. 

In some cases, this is a challenge, the team learned, as data integrity issues can make it difficult to determine risk. 

For the analysis, the team had a group of MRI safety experts review nearly 800 records of patients who had some sort of medical implant during the time of their scan. Of those cases, 16% had incorrect or incomplete implant or patient information. This could have impacted patient safety in nearly half of patients. 

Missing or incorrect data manuals were to blame for almost 80% of the safety information discrepancies. After realizing this, the department enacted a detailed review of all vendor manuals to ensure that the most up-to-date versions were available to staff. They created an online list of links to manual repositories for each active device the department encountered so that safety specifications could be verified. This resulted in significant improvements in the compatibility-verification process, the authors noted.

The group highlighted the importance of magnetic resonance safety officers (MRSOs) in maintaining these standards. At one point during the study, the department’s MRSO left their position, and the role was not immediately filled. This resulted in an uptick in staff consulting incorrect or outdated vendor manuals, as MRSOs were tasked with routinely updating the repository. 

The research comes after several high-profile MRI safety incidents that have renewed calls for standardized safety requirements. Currently, such guidelines are largely left to individual organizations. 

Learn more about the intervention here. 

Hannah murhphy headshot

In addition to her background in journalism, Hannah also has patient-facing experience in clinical settings, having spent more than 12 years working as a registered rad tech. She joined Innovate Healthcare in 2021 and has since put her unique expertise to use in her editorial role with Health Imaging.

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