Patient Safety Tip of the Week Archive

What’s New in the Patient Safety World

October 2024

Another MRI Accident Reveals Gap in Oversight

Yet another MRI projectile accident resulted in a near-miss regarding a patient (KTVU 2024, AuntMinnie.com 2024). A trainee reportedly brought a non-MRI-safe wheelchair into a California facility's MRI environment and "the wheelchair was sucked across the room, attaching itself sideways to the MRI scanner door, narrowly missing the patient."

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Thank goodness neither the patient nor anyone else was injured in this accident. Of course, we’d like to see the root cause analysis or incident investigation to see all the factors contributing to this accident. But the real story here is what followed the incident. It uncovered a striking gap in regulatory oversight.

MRI safety guru Tobias Gilk was apparently made aware of the incident by a witness. But public inquiry to the California Department of Public Health's radiological health branch was met with a statement that MRI is outside their jurisdiction. They referred the matter to the California Medical Board. The California Medical Board referred KTVU back to the California Department of Public Health because it said it does not oversee these types of medical offices. The American College of Radiology (ACR), which accredited the facility, told KTVU it does not comment on specific local site matters. ACR noted people can report incidents to them and facilities are subject to unannounced visits, but they do not regulate medical sites and sites are not required to report incidents, failures or injuries to them.

Turns out there appears to be a gap in California's statutory language regulating radiology, language that is specific to MRI. According to Gilk "Their statutes identify ionizing radiation devices (such as x-ray, CT, and nuclear medicine), but only recognize ultrasound and thermography the non-ionizing imaging modalities in the statute." "Their enabling statutes don’t even acknowledge that MRI exists.”

You may recall that, in our October 24, 2012 Patient Safety Tip of the Week “Serious MRI Accident at Unregulated MRI Center”, we noted a similar gap in regulatory oversight of MRI in Arizona.

We would think that CMS (Centers for Medicare and Medicaid) would want to review this recent incident. It was CMS that published the incident report of the serious MRI accident in a California hospital that we detailed in our November 21, 2023 Patient Safety Tip of the Week “Another Terrifying MRI Accident”.

These cases uncover a striking gap in regulatory oversight that places patient safety and MRI safety at risk.

Some of our prior columns on patient safety issues related to MRI:

· February 19, 2008 “MRI Safety”

· March 17, 2009 “More on MRI Safety”

· October 2008 “Preventing Infection in MRI”

· March 2009 “Risk of Burns during MRI Scans from Transdermal Drug Patches”

· January 25, 2011 “Procedural Sedation in Children”

· February 1, 2011 “MRI Safety Audit”

· October 25, 2011 “Renewed Focus on MRI Safety”

· August 2012 “Newest MRI Hazard: Ingested Magnets”

· October 22, 2013 “How Safe Is Your Radiology Suite?”

· October 21, 2014 “The Fire Department and Your Hospital”