MRI Safety Week 2024: The State of our Union

The volume on the radio was set a bit too high, so that -coupled with the elevated stress of the person calling- the breaking sound filling the room startled both of them...

"We have a hand crush injury! Send EMS!"

This was part of a story told to me at a meeting of risk management people from across many different high-risk industries. The person telling me the story had been in her supervisor's office, telling her supervisor that she was afraid that, at the construction firm they both worked for, there'd soon be a crushing hand injury. She had gone into her supervisor's office with the recent data about an uptick in the frequency of safety officials noting incorrect hand-placement when working with heavy components and the failure to put gloves back on after taking them off to do small, precise work. In that meeting she had said that she was worried that these were indicators of a more serious accident to come. Her supervisor had just finished saying how he didn't think that those small infractions of safety practice -even if there were several of them- could be used to forecast a serious injury when that fateful call announcing the serious injury came in over the radio.

No, that isn't an MRI story, but it's illustrative of something that I suspect is parallel.

Recently, I concluded an on-site MRI safety assessment of a hospital network with several separate MRI sites. Now often times I get brought in when there are significant errors, or lapses in MRI safety and I get to be the guy to say, 'yep, you've got a serious problem,' while pointing to staffing, or training, or friction-filled relationships with external clinical groups... This site was not one of those.

While the provider wasn't picture-perfect, they really didn't share the most common weaknesses in MRI safety practice that I see at many others, but they still had had significant safety episodes. After a week of shadowing patient care, evaluating their sites, talking with staff, and reviewing their policies, I could only identify one major enterprise-level contributor... growth.

This provider was seeing significant growth in demand for MRI services, and also (and perhaps more importantly) in the complexity of MRI patients. Both of those types of growth were putting more and more stress on an operation that might otherwise be really resistant to cracking under pressure.

Even if your MRI service isn't seeing growth in the form of referrals for more and more studies, the growth in patient and exam complexity is just about universal across MRI providers, in the United States, at least. That growth in complexity, alone, is enough to stress your safety practices.

This hospital provider that I was working with had an active performance improvement process. They had more-than-just-adequate staffing. They had engaged techs, and rads, and nursing, and anesthesia.

How can you have all that and still find yourself backsliding when it comes to MRI safety?

Because MRI risk isn't interested in a fair fight. We think that improving our processes (whether that's staff training, policies, zone signs... whatever) automatically means that we'll be in a world of lower risk after we make those improvements. And while it's probably true that you'll be better off than you would have been had you not made those changes, being 'better than I was yesterday' doesn't necessarily mean having a lower risk than you did yesterday.

You see, MRI risks are growing... quietly... steadily... insidiously. We think that improvement -any improvement- will protect us, but that presumes an unchanging risk environment. MRI risks are changing, quickly, and the rate of that change appears to be accelerating. So if you want to reduce your MRI risk you don't merely need to improve, but you have to improve at a rate that is faster than the growth in risk.

This is all preamble to my MRI safety 'state of the union,' which is somewhat grave...

I feel like my friend at the beginning of this piece, announcing that I see the indicators of something disastrous in the world of MRI. I sincerely hope that in several years we can all look back at this forecast of mine and laugh at how remarkably wrong I was, and I will very much enjoy the chance to eat crow then. The recent on-site visits with the provider who was doing a really good job, however, has illustrated for me just how pervasive and potentially dangerous the growth stresses may be for MRI.

While it may simply be more people sharing information with me about accidents, and not an increase in actual accident numbers, it doesn't feel like that to me. The recent spate of projectile injury reports I've seen (and many -those for which I had permission- I've shared) which have included injuries to technologists, patients, tech aides, trainees, service personnel, nurses, and visitors / companions, or very-near misses, seem exceptional in my experience of cataloging MRI accidents for the past couple decades. And however many projectile accidents there are, FDA data would suggest that nearly 2x that number is how many MRI burn events there are.

The risk environment is changing... and not in good ways.

In the MRI world (at least in the United States), we're seeing waves of retirements or promotions (to positions out of MRI) of those who had been senior MR techs. A radiologist friend of mine told me a year ago about how 40% of their MRI tech staff were agency techs because their hospital just couldn't hire enough bodies, irrespective of their experience. Today, in 2024, the ACGME (the group that sets the minimum training requirements for all the medical specialty residencies in the USA) has zero minimum requirements for MRI safety training of radiology residents. We're seeing an unprecedented 'balkanization' of MRI services, with specialty devices in radiation oncology, nuclear medicine, NICUs, EDs, ICUs, meaning that MRI safety knowledge and expertise is often needed in many different locations of an institution, even if there's only one radiology department. And we're seeing an explosion of MRI patients in whom there are implants / devices / foreign bodies... patients who would almost universally have been prohibited from receiving MRIs 25 years ago.

We're not nearly as protected as we might think we are.

As I've stated elsewhere, at the present moment not a single US accreditation organization has MRI safety standards that actually require the practices that we know would be highly effective at preventing MRI injuries. Furthermore, it would seem that none of them even do the QA that would indicate to them that their accreditation standards don't come close to fulfilling their promises of safety.

The feds don't prospectively regulate MRI safety at the point of care at all. There is the potential for retrospective wrist-slapping by CMS, after an MRI accident has happened, but CMS won't even tell you what standards or practices they'll use to evaluate you, and often investigating those accidents depend on self-reporting, which is notoriously unreliable.

States have the authority (but apparently not the willingness) to regulate MRI safety at the point of care. I would like to be able to say that MRI is suffering along with the rest of radiology as a result of many states' efforts to deregulate radiology care, but virtually no states have had any MRI safety regulations to even contemplate rolling back. In another recent article I noted how the State of California's administrative code (which empowers the California Department of Public Health) doesn't even acknowledge that MRI exists!

At the moment, virtually all of the responsibility for safe MRI practices falls at the feet of the individual hospitals and imaging centers, with almost zero enforceable standards that are helpful in preventing MRI accidents. And if the hospital group that is doing almost everything right is backsliding when the risks are advancing faster than they are, what does that suggest for everyone else?

It suggests that we're all in for a rocky ride. It suggests that MRI safety will get worse before it gets better. It suggests that there will be high-profile MRI accidents and CNN coverage with more aghast expressions of 'how could this have happened?' or 'nobody could have anticipated a freak accident like this.'

But I don't actually have a crystal ball, and I can't tell what the future will hold. Based on the direction we're headed I'm very worried, but there is time to change course and point towards a better future where we do a better job of managing MRI safety risks. That's likely going to take a lot of work, requiring tools and solutions that we haven't needed before now. Time to roll up our sleeves and fix things before the radio squawks out something we very much don't want to hear.