MRI Safety: Minimizing Risk

Posted by

By Zachary W. Friis, PhD, DABR, MRSE

2017 will mark the 40th anniversary that Dr. Raymond Damadian used Nuclear Magnetic Resonance Imaging (NMRI) to image the human body for the first time. Over the past 40 years, MRI has become an indispensable diagnostic imaging modality and the initial method of diagnosis for numerous diseases and conditions. Improvements in technology have resulted in higher patient throughput while providing amazing clinical images without exposing patients to the negative effects of ionizing radiation. MRI is truly a modern day medical marvel.

Many working in diagnostic imaging tout MRI as a “safe” imaging modality because it does not use ionizing radiation, which has led to an air of complacency in and around the MRI suite. Without the need to monitor radiation exposure or wear thick layers of lead, people often forget the inherent dangers of working around and using strong magnetic and gradient fields, as well as radio frequencies that cannot be seen or felt. Despite massive technological advancements in MRI, the number of reported safety incidents has increased significantly since its inception.

An incident in 2001 demonstrated the gravest consequences of neglecting MR safety with the death of a six-year-old boy at an upstate NY hospital who was undergoing a routine MRI of the brain following the removal of a benign tumor. The patient was required to receive general anesthesia during the MRI scan, and during the procedure there was a loss of medical oxygen to the patient. The anesthesiologist monitoring the young boy shouted to other medical personnel in the MRI suite for additional oxygen. A nurse in the hallway answered the call by bringing a ferromagnetic (not MRI conditionally safe) oxygen tank into the scan room. The oxygen tank became a high-impact projectile and was attracted into the bore of the magnet, fatally striking the patient in the head.

During the same year, the American College of Radiology (ACR) formed a blue-ribbon panel of MRI industry experts to address MR safety. This panel’s diverse participants included MR physicists, radiologists, technologists, patient safety experts, and Food and Drug Administration representatives, among many others. Together, they created a guidance document for safe MR practices that encompassed a multitude of topics. The ACR Guidance for Safe MR Practices has evolved many times throughout the years; the most current version is from 2013. Despite the comprehensive nature of the document, the guidance document is essentially a suggestion for sites to use.

However, the imaging industry has now begun making MR safety a priority requirement and not just a recommendation. In 2015, the ACR began requiring that medical physicists complete an MR Safety Checklist each year during their annual performance evaluations. That same year, The Joint Commission also released new standards that for the first time included several MR safety-related elements of performance. The Joint Commission recently compiled a list of the most frequently cited areas of non-compliance and MR Safety was still ranked #1 for 2 consecutive years compared to other modalities.

To learn about more developments in MR safety, please join me on Tuesday, October 31 from 2:00- 3:00 PM at the AHRA Virtual Fall Conference for my session, “MRI safety – How the industry has responded to minimize risk?” If you can’t watch my session live, you’ll still be able to view a recording as long as you’re registered for the conference.


Zachary W. Friis, PhD, DABR, MRSE, is a board certified Medical Physicist and MR Safety Expert at West Physics. He can be reached at zach@westphysics.com.

3 comments

  1. Can anyone give me a reference document for MR Safety as it pertains to staffing model or number of techs/aids required? I know the 2013 Guidance document had a small section about having someone in the “immediate Zone 2 area”. But beyond that, has any new standards been set to aid in enforcing a minimum staffing level?

  2. 2013 ACR guidance document page 10
    “C. MR Technologist
    1. MR technologists should be in compliance with
    the technologist qualifications listed in the MR
    Accreditation Program Requirements.
    2. Except for emergent coverage, there will be a
    minimum of 2 MR technologists or one MR tech-
    nologist and one other individual with the desig-
    nation of MR personnel in the immediate Zone II
    through Zone IV MR environment. For emergent
    coverage, the MR technologist can scan with no
    other individuals in their Zone II through Zone IV
    environment as long as there is in-house, ready
    emergent coverage by designated department of
    radiology MR personnel (e.g., radiology house
    staff or radiology attending).”

    ***At my site we interpret this blurb from the ACR white paper guidelines- as 2 “safety trained” MRI staff need to be in MRI at all times when a pt is being imaged. We require either 2 techs, or 1 tech and a 1 MRI tech aide in the technical area if a patient is actively being scanned.

  3. Disconcertingly, when evaluating the root causes of MRI injury accidents, the OVERWHELMING majority of reported injury accidents (e.g. 97% of burns and 94% of projectile accidents) would have been prevented through the use of the concrete, explicit recommendations of the ACR Guidance Document on MR Safe Practices.

    So we know what causes MRI accidents. We know the effectiveness of specific preventions. So why is it, as Dr. Friis notes in his article, that the rates of reported MR accidents has climbed so much faster than any organic growth from procedure volume?

Post a Comment

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s