By Tobias Gilk, MRSO, MRSE
By now you have likely heard of the fatal MRI accident that occurred in the days just before the annual MRI Safety Week recognition. As I write this, we’re all still in the thinning haze of hearsay and fourth-hand reports, painfully slowly being displaced by substantiated facts.
There are the obligatory call-backs to the infamous 2001 Colombini MRI fatality, with lots of variations on the freak nature of ‘lightning striking twice,’ or how accidents like this are ‘unprecedented’… even ‘unimaginable.’ None of that is correct. This was not a ‘freak’ accident. It isn’t unprecedented (just look online for pictures of things stuck to MRI scanners), and ‘unimaginable’ is more an indictment of someone’s lack of imagination than an objective statement of fact.
To be clear, there is a lot yet to be learned about this incident, and that will inform the analysis of what or who failed to prevent this fatal accident, but let’s distill this to the absolute minimums: MRIs are giant magnets and will attract magnetizable objects with exceptionally dangerous force. Neither of these truths should be surprising, and they are foundational tenets of many MRI safety protections, which include:
- Screen persons & equipment for MRI risks before letting them close to the MRI
- Strictly control access to the hazard areas of the MRI suite to only the successfully screened
- Staff MRI areas with appropriate numbers of MRI safety trained personnel
We don’t know which of the foundational tenets in the short-list, above, were violated in this recent accident, but – short of teleportation or other miracles – it’s virtually guaranteed that at least one didn’t live up to the… ummm …
I almost wrote “standards.”
Herein lies MRI safety’s greatest problem. MRI has an impressively thorough body of best practices (what CMS would call “professionally approved standards”) which very clearly articulate practices that would have made this recent accident impossible. But in what comes as an ugly surprise to most, virtually none of these specific point-of-care MRI safety best practices actually show up in state licensure requirements, accreditation standards, CMS Conditions of Participation, or other payor minimums. Our healthcare safety structures have been ignoring the low-hanging fruit of preventable MRI accidents and injuries, and now we have a clearly preventable fatality as the bill for that indifference.
There will be recriminations, and lawsuits, and blame-assignment… all of that will form from the wreckage of this incident, just as it did following the Colombini accident. We might parse responsibility among the owner of the imaging center, their policies & practices, the MRI technologist, and the victim. What I want us to remember and consider is that – unlike ionizing radiation – it appears that there was no entity with ‘big picture’ safety responsibility defining or enforcing minimum effective standards.
The New York State Department of Health has said that this provider was exempt from state licensure regulation. But even if they did have jurisdiction, most state’s licensure standards dedicate section-upon-section of state codes to ionizing radiation but often even fail to mention MRI, much less establish minimum safety standards for the modality. So far, we also haven’t been able to identify any accrediting organization for this site. Again, even if we do, most accreditation organizations’ MRI safety standards eschew specific preventions in favor of broad hand-waving ambiguous sweeping language (e.g., ‘employ safe practices’ or ‘informed by best practices’), leaving the use of specific, established safety practices largely to the discretion of individual provider organizations.
Twenty-four years ago, after the Colombini accident happened, there was a resounding ‘never again’ chorus that arose from the radiology professional community. It was that reaction which launched the ACR’s MRI safety publications that have defined MRI safety best practices and established the MRI safety standard of care for twenty-three years now. We don’t lack the specific practices that would have prevented this death… those exist.
MRI patients and workers deserve functional minimum MRI safety requirements. My fear is that if we don’t codify existing best practices in the minimum standards (I’m looking at you, CMS, and the individual state departments of health, and all of the accreditation organizations), in another ten or twenty years we’ll all be gathered around another preventable MRI tragedy, metaphorically staring at the tops of our shoes, wringing our hands and calling the new incident ‘unprecedented’ or an ‘unimaginable freak accident.’
We have a second opportunity to codify MRI safety best practices into standards. This second chance has been paid for in blood. Let’s not let this slip through our fingers … again.
–Tobias Gilk, MRSO, MRSE, is a RAD-Planning & Gilk Radiology Consultants Principal.
