The Joint Commission, alarmed at hundreds of MRI-related accidents over the last decade, recently issued a Sentinel Event Alert and a call for increased safety measures in the MRI suite.

“While the capabilities of the MRI scanner are well-recognized, its inherent dangers may not be as well known,” The Joint Commission said, citing a Food and Drug Administration (FDA) study.

A 10-year study reveled 389 incidents, including 9 deaths. The most common patient injuries are burns and the most common objects to undergo significant heating are wires and leads. Other objects associated with burns include safety pins, metal clamps, drug delivery patches (which may contain metallic foil), and tattoos (which may contain iron oxide pigment). Less common injuries involve pacemakers, which, along with cardioverter/defibrillators,  are considered by the American College of Radiology (ACR) a contraindication for MRI.

The Joint Commission recommends:

• Restrict access

• Screen non-emergent patients twice for metal objects or implants

• Ensure complete medical histories of patients

• Have trained personnel accompany patients, visitors, and other not familiar with the MRI environment

• Annual safety training for any staff who might enter the MRI suite

• Take precautions to prevent burns

• Use only appropriately tested equipment (including fire extinguishers, oxygen tanks, and monitors)

• Plan for managing critically ill patients who require physiologic monitoring and continuous infusion while in the MRI suite

• Provide hearing protection for patients

• Never attempt a cardio-pulmonary arrest code or resuscitation within the magnet room

For more details, visit The Joint Commission’s Web site.