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Joint Commission Alert Shines Light on Preventing MRI Accidents, Injuries
Date:2/15/2008

nel Event Alert newsletter recommends that health care organizations take the following steps:

-- Restrict access to all MRI sites by creating safe zones recommended by the American College of Radiology (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 Joint Commission. Much of the information and guidance provided in these Alerts is drawn from the Joint Commission's Sentinel Event Database, one of the nation's most comprehensive voluntary reporting systems for serious adverse events in health care. The database includes detailed information about both adverse events and their underlying causes. Previous Alerts have addressed wrong-site surgery, medication mix-ups, health care-associated infections, and patient suicid
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SOURCE The Joint Commission
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