Patient Safety Tip of the Week Archive

Patient Safety Tip of the Week

April 22, 2025

Updated ACR Manual on MRI Safety

We’ve actually mentioned the updated ACR® Manual on MR Safety in several previous columns. It has been available for quite some time. But it was just formally published in the journal Radiology (Pedrosa 2025).

The manual begins with recommendations about the management structure of the facility, which “includes an MR Medical Director (MRMD), an MR Safety Officer, and an MR Safety Expert, with the roles and responsibilities of such individuals clearly defined.” You’ll recall in our November 21, 2023 Patient Safety Tip of the Week “Another Terrifying MRI Accident” a very ambiguous management structure likely was a contributory factor to an MRI accident.

It also strongly recommends an MR Safety Committee including those in the management structure plus other pertinent stakeholders. That committee should meet regularly and review and report MR-related adverse events, safety incidents, “near misses,” and other MR safety issues so that policies and SOP’s (standard operating procedures) can be updated as needed in an effort to prevent future incidents. It also has a comprehensive list of suggested policies and SOP’s for MRI facilities in Appendix 1.

It has extensive discussion on facility design, including multiple diagrams. That includes each of the zones and includes discussion about personnel and staffing and the respective roles, credentials, and training. This includes a table with common key elements of MRI safety training expected for Level 1 and Level 2 MR personnel.

As you’d expect, it has a thorough discussion on MR screening. There is also a table noting common implanted and on-planted devices in patients undergoing MRI.

Our regular readers know we are fond of using checklists. The manual has a checklist for “full stop and final check” analogous to the timeout we perform prior to surgery or other invasive procedures. There are actually 2 checklists, one for “routine” patients and another “augmented” one for special circumstances (like comatose patients or those with multiple medical equipment needs).

The manual notes that special considerations exist for certain personnel, patients, or research participants in the MR environment. Examples include pregnant health care providers, patients, or research participants, as well as individuals experiencing claustrophobia or anxiety or requiring sedation, those with a large body habitus, and prisoners or detainees. We already discussed those in our October 2024 What's New in the Patient Safety World column “MRI Special Patient Considerations”.

It also has a section on issues related to “alternative MR environments” (like perioperative MRI).

It notes that MRI facilities should develop policies and SOP’s to address emergent situations specific to their equipment and environment. That discussion includes training for the function and location of various emergency switches, like emergency stop, emergency power off, and emergency magnet off (quench). You’ll recall that in several of our columns on MR incidents, there was a lack of clarity by staff about such emergency switches and their authority to use them.

Our one concern is that the manual does not appear to address the need for training police, firemen, other first responders, prison guards, and any outsiders who might have need to be at an MR suite for emergencies. Many of our columns have discussed that particular need (see, for example, our October 8, 2024 Patient Safety Tip of the Week “First Responders and MRI”). It does state that policies and SOP’s should address the

response to fire emergencies and rapid clinical deterioration but we’d like to see a section dealing with the specifics of training those “outsiders”.

Overall, the updated manual is a resource any facility or organization doing MR scanning needs to review on a regular basis.

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”