The Need for MRI Safety Education StandardsBarbara NugentRoyal Hospital for Sick ChildrenEdinburgh

Contents

Do the statistics reflect the no. of

incidents and what can we learn from

incidents?

Can eLearning help improve safety

practice and what else is needed?

New technologies, new concerns

2005-2009 a 180% (FDA) or 500% ↑ incident reporting – which is it?

Texas studyProjectile incidents

happen every month

Each scanner due a serious incident

every 5yrs

Dr Kanal described that the reported

FDA incidents were not ‘even the tip of

the iceberg’

Typical UK reports -incidents reported to the MHRA 2014

What could possibly go wrong?

70% of radiographers (BAMRR) witnessed MRI safety incidents, but > 80% were not reported to the MHRA

3https://www.sor.org/learning/library-publications/imaging-therapy-practice/january-2017/posters-imaging-therapy-practiceReproduced with kind permission from Frank G.

Shellock Ph.D., FACR, FISMRM

If we knew the number of incidents that occur would that help to prevent them from happening?

Can we learn from cylinder incidents and when will they stop?

Not stopping any time soon - *MAUDE April 2017

GE scanner

Anaesthetist brought a ferrous oxygen cylinder into the scan room while staff were preparing a patient for their scan

The cylinder hit a physician in the room, resulting in a fractured nose

What we can do is train staff in how to deal with incidents in MRI when they happen using drills and simulation but who has the time?

* Manufacturer and User Device Facility Experience

Death of a patient’s relative, told to take in a ferrous oxygen cylinder, January 2018 (Radiologist scanning)

Warning signs and posters do not work!

The Missile Effect

Reach speeds of >

80 kph at 1.5TAcceleration 10 x gravity

Sticks with a force >150 x

gravityReproduced with kind permission from Frank G. Shellock Ph.D., FACR, FISMRM

Burns are the most reported incident

The most reported MRI adverse

incident (England) is due to burns

70% of all injuries in MRI attributed to

burns

Radiofrequency fields used in MR create thermal heating leading to:•heat stress•induced current burns•contact burns

6. MHRA 2.4.37. http://www.jointcommission.org/assets/1/18/SEA_38.PDF.8. MHRA 2.4.1

Skin can be a dangerous conductor

We need to teach how to position patients safely

Reproduced with kind permission from Frank G. Shellock Ph.D., FACR, FISMRM

Capsule Endoscopy August 2017

Pill sized capsule contains a colour camera, battery, light and transmitter.

Takes 2 pictures/sec. for 8 hrs.

Near miss as referring doctor omitted to mention it and the patient forgot.

Demonstrates the need for safety education for referrers

Magnetic rods – Conditional but only if the patient doesn’t move!

Spinal Growth Rods Limb Lengthening Rods

Would you ever have the time to train staff to know what to do in every emergency in MRI?

Medical Projectile Quench Power cut Fire Flood

Generic MRI safety training working party

NES: Barbara Nugent

IPEM: Geoff Charles-Edwards, Annie

Papadaki, Peter Wright, Dan Wilson, Cormac

McGrath, Jennifer MacFarlane

MHRA: David Grainger ISMRM British Chapter: John Thornton SoR: Alex Lipton

BIR: Martin Graves, Sarah Adibi

BAMRR: Paola Griffiths, Janine Sparkes

AAGBNI: Sally Wilson, Samantha Shinde

e-learning for Healthcare: Neha Baj,Patricia Howe

RCR: David Lomas

1st Safety Module on the safety aspects of dealing with anaesthetic sessions now available

On the elfh Learning Management System MRI Safety :http://www.e-lfh.org.uk/programmes/mri-safety

On the Image Interpretation project with CoR:

http://portal.e-lfh.org.uk/Account/logon

http://portal.e-lfh.org.uk/Component/Details/455438

Provides evidence of safety training

Can record it in your CPD portfolios for professional

accreditation and regulatory (HCPC) purposes

Directly addresses the MHRA recommendation that an

MR unit should maintain full details of the training and certification of Authorised

personnel

Is eLearning an appropriate way to learn about how to mitigate MRI risks and hazards? Global evaluations n=90

97% would recommend the module to a

colleague

86% consider eLearning to be the most

appropriate way to disseminate

standardised MRI safety education

75% see this learning improving their working

practice

7. Over a quarter believe that it should be mandatory for staff to have this knowledge

Very important44.8%

Essential26.4%

Should be mandatory

27.6%

Optional1.1%

Module provided new knowledge

80% said the content contained new learning for them and that they would use this module again for information

Over half will now introduce the GA safety

pathway

Learning had a positive impact on staff confidence regarding safety in the MRI unit

>60% feel more confident now when

dealing with anaesthetic sessions

>50% feel more confident now dealing with safety during MRI

sessions and will change their working practice

93% of reviewers would now like to see these modules produced

55.6%

84.0%90.1%

79.0%

51.9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Understanding the MRIunit: layout and access

Electromagnetic fields andtheir effects: static;

gradient; RF

Dealing with emergencies:quench; medical; fire;

flood; oxygen depletion

Safety of MRI contrastagents

Incident reportingprocesses

Perc

ent

So where do we go from here?

Experts ready to review and

accredit a suite of safety modules

Finance and time required to

produce other modules

Other goals for improving MRI safety in Scotland

Ergonomic analysis of MRI units

Pocket-less MRI uniforms/staff and/scrubs for

patients

Scottish MRI Leads incident categories

being adopted across health boards

MRI Adverse Event –6 MRI Safety Subcategories for Reporting systems

Typical examples of incidents which fit this category

Non Declared Internal Passive Metallic Implant aneurysm clip, coils, stents, filters, prosthesis

Non Declared Internal Active Metallic Implant pacemaker, cochlear implant, neurostimulator, baclofen pump, insulin pump

RF Heating or Burn Incident flesh loops, cable heating, long metal implants, retained wires, equipment related

Equipment Failure oxygen sensor, fire, flood, contrast injectors, quench

External ferromagnetic object/ Projectile oxygen cylinder, chairs, trolleys, drip stand, coin, lighter, pen, badge, pager, phone, glasses, earring

Breach of Local Rules unauthorised access/inadequate supervision of unauthorised staff, equipment wrongly labelled

Other Any MRI incident which cannot be classified above

In summary - a range of methods needed to mitigate MRI risks and hazards

Lack of standards of safety educationPhysical conditionsHuman factorsOperational systems of workCulture

Systemic failures