HospitalInspections.org

Based on record review and interview, the facility failed to protect patients and staff from magnetic risk in the Magnetic Resonance Imaging (MRI- a medical imaging technique used in radiology to investigate the anatomy and physiology of the body, using strong magnetic fields and radio waves to form images of the body) for one (#28) of one patient in the MRI department. This failure to protect patients and staff from the magnetic risk by allowing ferromagnetic equipment (containing magnetic iron) to enter the MRI field had the potential to cause injury and even death to patients and or staff. The facility performs on an average 230 MRI studies per month. The facility census for the main hospital was 139. Facility census for the other hospital campus was 64.

Findings included:

1. Review of the facility's policy titled, "MRI Patient and Environmental Safety," with a review date of 10/11, showed the following direction:
- All health Care employees are responsible for providing a safe environment in the MRI Department to prevent injury to patients, employees and equipment damage.
- Any individual's access to the MRI Suite, MRI Zones three and four, is granted only after successful completion of the MRI screening process.
- Access to MRI Zones three and four is allowed at the discretion of the MRI Technologist and MRI Supervisor/Lead.
- All equipment brought into MRI Zone three must be evaluated for safe use in the MRI environment by the MRI Technologist or MRI Supervisor/Lead before being allowed into MRI Zone Four.
- At facility only, ferromagnetic equipment is not permitted in MRI Zone three for hospital inpatients.
- Equipment that is not listed as MRI Conditional or MRI Safe is not allowed into MRI Zone four. The list of items includes but is not limited to:
- Ferrous (iron) objects, equipment, and items
- Oxygen Tanks
- Wheelchairs
- IV (intravenous) poles
- Housekeeping/Cleaning Equipment
- Patient transport into MRI Zone four must be done with MRI compatible equipment.
- Patients requiring wheelchair transfers must be taken into MRI Zone four upon a MRI safe wheelchair.

Record review of facility's policy titled, "MRI Safety Screening," with a review date of 10/11, showed the following direction:
- All patients having an order for a MRI procedure are required to complete the MRI safety screening process before entering the MRI suite. It is at the discretion of the MRI Technologist, MRI Supervisor//Lead, Medical Director and/or Modality consultant to allow access to MRI.
- It is at the discretion of the MRI Supervisor/Lead, MRI Technologist, Medical Director/Radiologist or MRI Modality Consultant to allow access to the MRI environment upon completion of the MRI Safety Screening Process.
- All persons, prior to entering the MRI Zone two, must complete a MRI Safety Screening form.

Record review of the MRI Safety Screening form showed the following patient direction: "Before your MRI please remove all metallic/magnetic objects including keys, hairpins, barrettes, jewelry, watch, safety pins, paperclips, money clips, credit cards (wallet), coins, pens, belt, pocket knife, any metal objects."

2. Record review of facility event report documentation of an MRI event on 09/30/14 showed:
- Patient #28 was on the MRI table at the foot of the table.
- Staff CCCC, Clinical Partner/Transporter, entered Zone four with a ferromagnetic wheelchair.
- Staff CCCC and the wheelchair were wedged in the corner of the gantry (opening of the MRI machine) next to the table on the MRI machine.
- Staff CCCC received a "scratch" to her shin during the process.

3. During an interview on 10/08/14 at 3:35 PM, Staff CCCC, stated:
- I just wasn't thinking.
- I didn't realize the force of the magnet.
- I didn't think wheelchair would be a magnet.
- I didn't see the sign related to equipment
- I had training on MRI safety but I just didn't get it.

4. During an interview on 10/08/14 at 2:55 PM, Staff EEEE, MRI Technologist, stated that she failed to have Staff CCCC fill out a MRI Screening Form. She stated that she was helping the patient get up and did not see Staff CCCC bring the non-safe MRI wheelchair into the room.

5. During an interview on 10/09/14 at 10:30 AM, Patient #28 stated that she was concerned for the staff. She stated that the staff person should not have brought the wheel chair into the room.

6. During an interview on 10/09/14 at 8:30 AM, Staff D, Regulation/Risk Coordinator, stated that she felt the MRI safety training prior to the event was not adequate.