Help Promote MRI Safety at Your Facility

By Sue MacIntyre, CRA, MHA, R.T(R)(MR), MRSO (MRSC)

This July marked the 20th anniversary of the death of Michael Colombini. Colombini was having an MRI when a nurse handed a ferromagnetic oxygen tank to the anesthesiologist that was tending to Colombini in the scan room.

The tank became a projectile, hitting him in the head, and three days later, he died from blunt force trauma. It was estimated that the oxygen tank hit Colombini at a speed of 45 miles per hour. As a result of this MRI accident and others, the American College of Radiology created a blue-ribbon panel for MRI safety that year. In 2002, the panel published the first white paper on MR safety. The document was intended to be used as a template for MR facilities to follow in the development of an MR safety program.[1] This publication was recently updated to the ACR Manual on MR Safety. Discussing safety recommendations for MR facilities, the document is of immense value to any imaging professional.

MRI has continued to grow as one of the most accurate modalities in health care. Where are we now in MR safety? Unfortunately, not much has improved. There are few state or federal regulations. MRI accidents are on the rise, little has been done to put provisions in place for developing these recommendations into regulated standards. The ACR’s document contains measures for providing an MR safe environment. To date, no organization, including the ACR, has responded by requiring those safety provisions to be in place prior to receiving accreditation or compliance approval.4 The Joint Commission has published articles for their members about MRI accidents, but they have not selected a specific MRI criterion for on-site surveys.[4]

There are important safety needs unique to MRI: zoning restrictions, specialized non-ferrous equipment, appropriate staffing levels, ferromagnetic screening and hazard warning signs. All of these can help keep patients, visitors and staff safe while in the MR environment. The root cause analysis from the Michael Colombini case caused the MR industry to realign its safety measures. Over the past 20 years, most of the industry has valued the information learned from the Colombini accident, but we have a long way to go in placing standards and regulations in MRI safety practices.

Help promote MRI Safety at your facility:

• Appoint an MRMD MR Medical Director/Physician[2]
  • MRSO (MR Safety Officer) and MRSE (MR Safety Expert)
• MR technologists should comply with the technologist qualifications listed in the ACR MRI Accreditation Program requirements.[3]
• Develop MRI policies and procedures and update annually[2]
• Personnel needing to enter Zone III must first pass an MR safety screening process.[2]
• Follow ACR recommended staffing[2]
  • (2) MR Personnel per unit (Level I and Level II)[2]
• Zone your MRI department into Four Safety Zones[2]
  • Zone I: General Public
    • Free access
  • Zone II: Interphase between zones, patient triage/gowning
    • Supervised by Level II (Technologist)
  • Zone III: Restricted/Controlled by Level II Personnel
    • Screened personnel only
    • Restricted
  • Zone IV: Magnet Room
    • Highly restricted

References:
1. American College of Radiology. White Paper on MR Safety. 2013. Accessed June 3, 2021
2. American College of Radiology. Manual on MR Safety. 2020. Accessed June 3, 2021
3. American College of Radiology. ACR MRI and Breast MRI accreditation personnel requirements 2019. Accessed March 24, 2020.
4. Tobias Gilk and Robert J. Latino. MRI Safety 10 Years Later. 2011. Accessed June 11, 2021.