The Year Of Living Safely?!

By Tobias Gilk

Yes, it was one full year ago this month that we alerted you to the imminent release of MRI safety sentinel event from the Joint Commission. Late in 2006 the Joint Commission’s Sentinel Event Advisory Board authored what was to become Sentinel Event Alert number 38 on MRI safety. In February of 2007, the as yet unreleased Alert was revised in the wake of the release of the ACR’s Guidance Document for Safe MR Practices: 2007. To the best of our knowledge, the revised manuscript for this alert has been ready and awaiting release since March, which begs the question, “why haven’t we seen it?”

Has there been a 180-degree turn-around on the assessment that there are critical MRI safety issues that the Joint Commission should address? Did the Joint Commission feel that it needed to develop new standards that addressed these issues before the Alert was released? Have the personnel changes at the senior administrative levels – both past and forthcoming – derailed efforts to release the Alert?

In July of 2007, Joint Commission Resources, the consulting arm of the Joint Commission, held a teleconference in which they too announced the impending release of the MRI Sentinel Event (along with another on pediatric medication errors and one addressing assaults). It would seem that the confusion about the release of the anticipated Alerts (or at least it’s ‘impending’ status) extends well up into the Joint Commission organization’s own ranks.

It can’t be that the past 12 months have seen a positive sea change in MRI accident rates. The continuous stream of anecdotal reports we receive of floor polishers, medical gas cylinders, furniture and tools that all wind up in the bores of magnets suggests that there is no marked improvement. In fact, throughout all of 2006, the FDA recorded 83 safety reports on MRI. As of October of this year, the number of reports to the FDA has already exceeded last year’s tally, suggesting that the year-end total will see a 20% increase in reported incidents.

What has changed since this time last year (beyond the roughly 30 million MRI scans completed in the United States)?

• The American Cancer Society has called for annual breast MRI exams for over a million US women determined to be at high-risk.
• The number of facilities providing MR-guided biopsies has increased dramatically.
• More powerful 3.0 Tesla magnets are becoming increasingly common.
• Intraoperative MRI is continuing its slow and steady progress.

None of these factors are doing anything to diminish the risks to MRI patients. In fact, quite the opposite; we are moving greater numbers of patients through diagnostic and increasingly interventional procedures. This is a trend that shows no signs of abating.

The latest ‘back-channel’ word from the Joint Commission is that the MRI Sentinel Event Alert will be released early in 2008. Of course, we will share information about the release as soon as we are aware of it, but we’ve long-since exhausted our ability to hold our breath in anticipation.

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