The need for a universal template to harmonise MRI incident reports

Selecting only suitable categories for reporting MRI incidents could potentially improve reporting rates and incident analysis. If adopted internationally, the results could harmonise reporting globally.?

The following discussion is based around my article published in last month's RAD Magazine which is now free to download: The need for a universal template to harmonise MRI incident reports.??

Accurate incident data is crucial for incident prevention

If appropriate controls are in place, almost all risks and hazards associated with MRI can be mitigated. For various reasons, adverse events continue to occur and neither national nor international reports accurately reflect all the reasons why. Inadequate incident data hinders the ability of regulators and those responsible for managing safety to introduce all the necessary preventative measures. With accurate statistics on the amount and types of incidents occurring, controls and strategies to reduce MRI incidents may be more precisely employed.

MRI incident reporting is generally inadequate

While there are many ways to report MRI incidents, reporting rates remain generally poor. It’s believed that the number of incidents recorded reflect a very small percentage of the true number of mishaps. Judging current incident reports as any sort of indicator of the safety level of MRI practice is therefore inappropriate. Similarly, the suitability of some preventative measures put in place to try to prevent accidents is not guaranteed if the success of any measure is made against any drop in the number of incidents reported. If the supplied incident data is insufficient in the first place how can the success or suitability of any controls be assessed?

Inappropriate terms used for reporting incidents hinders data analysis

Due to the variety of reporting systems and templates in use, few units record MRI incidents in the same way. Inappropriate and diverse terms may be used to describe the same types of incident, masking potential trends. Even where reporting rates may be good, the lack of comparable descriptions and detail hampers obtaining good data across sites. MRI reporting systems are generally unfit for purpose if the outcome is that MRI incidents are either wrongly classified using ill-chosen narratives or the incident is placed under a broad heading such as ‘equipment issue’ with no simple way to clarify or identify the incident further. The lack of harmonisation over categorisation and wording complicates trying to correlate terms or even to identify if the report relates to an MRI safety incident. Any difficulties encountered in recognising or classifying incidents limits the scope to analyse the cause and to find safety solutions.

Why do the same types of MRI incidents occur?

A brief look through a variety of MRI reports from various healthcare organisations indicates that the same types of incidents seem to recur. Ferromagnetic wheelchairs and floor buffers are examples of the types of objects that continue to be found stuck against these powerful magnets. Very few MRI units, however, have found it possible to implement a truly ferrous-free culture or implement ferromagnetic detectors, even though the latter is recommended by the MHRA (1). The strongest barriers to accidents occurring in MRI units are often the preventative actions performed by MR radiographers. Projectile incidents appear to occur fairly regularly, but the reports to the MHRA do not reflect this. Patient burns are very rare but are the most reported MRI adverse event.

Mandating that all MRI incidents get reported could reveal the true extent of mishaps

MRI system manufacturers are obliged to report certain adverse events but, to encourage reporting, these records are kept confidential. The regulator recommends that MRI incidents be reported by everyone else but does not make it compulsory. The consequences of a voluntary reporting system are that the workforce remain ignorant of incidents and is denied learning subsequent lessons. The same practice that led to the incident then gets repeated. So-called ‘never events’ remain ‘forever events’ if we fail to act in accordance with any potential recommendations made following an accident. Under-reporting is a global problem. The hazards associated with the electromagnetic fields are predominantly experienced by patients and MRI healthcare professionals though, not the manufacturers. Introducing a mandatory element to incident reporting and making the information publicly available could validate the need for improvements in MRI safety to be made.

A nationally agreed template would standardise incident reporting

Using a standardised template with agreed terms for classifying incident types will allow systems and users to categorise incidents appropriately and may save reporters’ time by removing any ambiguity. Ensuring that only relevant terms are used, as agreed by health care organisations, could provide greater clarity on the amount and types of incidents occurring. Specifying appropriate categories from which to select conforms to guidance that healthcare professionals should be encouraged and enabled to report incidents using harmonised formats (2). Clinical staff rarely have much time for reporting incidents. The time taken to report on some workplace systems can be laborious. Making the reporting form less arduous and time-consuming would be welcome. It is possible that the limited time available for reporting leads to the belief that only the most ‘serious’ incidents tend to get recorded.

The importance of recording ‘near misses’

Detailing a ‘near miss’ is an important part in the process to prevent accidents but the significance of near miss evidence is often overlooked. Near miss events are those where, only by chance, no one has been injured or equipment has been damaged. Not reporting these types of incidents potentially leads to a risk that the same types of practices continue and remain unexamined. Failure to record such events could result in a similar incident happening that eventually does result in injury. Consequently, poor incident reporting may lead to poor safety practice.

Suggested categories for inclusion in the MRI incident reporting template

Suggested categories for classifying incidents are proposed in the table below, modified from an earlier template first created by the Scottish MRI Lead Radiographers’ Group. Incidents are grouped under headings considered appropriate for identifying both common and nuanced types of MRI adverse events such as ‘external ferromagnetic projectile’ or ‘non-declared internal or attached active MR Conditional or MR Unsafe implant’. Any reporting system should also be designed to provide free text to clarify any incident further. As promoting a universal template with these suggested terms is novel, analysis of the events placed into the ‘other’ category may provide very useful data. Descriptions written up under the ‘other’ event may reveal necessary information to update or add new classifications, as required.

With input from users and MRI safety experts, wording and terms considered appropriate to categorise or group MRI incidents were included. If implemented across healthcare and modified according to user feedback, in time, a universally agreed incident reporting template could be produced. Using similar terms across sites may lead to a better understanding of MRI incidents. The risks and hazards of any imaging modality can only be realised if accurate incident figures are available and any learning from the event is shared. The subsequent data may result in greater awareness of the incidents occurring and universal strategies for their prevention.

With thanks for reviewing the original article to Frank Shellock, Ph.D. , David Grainger , Tobias Gilk and Rhys Slough

Related but not included in the Rad Mag article

Human Factors experts/Ergonomists – an underused resource in healthcare

Not included in the article but an important aspect of promoting safe systems of work is the value that safety scientists’ knowledge can bring. To reduce incidents, we might believe that introducing every safety intervention might keep people safe but if we underestimate or don’t understand what is needed to encourage people to follow any appropriate guidance, then no safety pathway will ever be robust. Healthcare would benefit greatly from employing professionals who are trained in analysing how workplace systems operate safely on a day to day basis. Input from Chartered Ergonomists and Human Factors Specialists can provide an overall systems perspective by accounting for the influence that all the interactions with people, technology and physical environments can have on individual safety behaviours. Their contribution can prove critical to the successful implementation of any interventions. Every MRI unit should have access to this valuable resource so that appropriate, safe pathways for patients, visitors and staff are designed based on evidence based practice. Academics with such backgrounds are doing sterling work trying to influence change. Having such experts directly employed as part of clinical governance teams could have a significant impact by improving all types of safety decisions made, from the design of departments to assessing the practicality of any proposed safety processes. (I have gained some understanding of this scientific discipline from: Paul Bowie , Laura Pickup and Steven Shorrock )

Is there really a ‘no blame culture’ when reporting incidents?

A ‘no blame culture’ is promoted in healthcare to try to create a safe place to encourage incident reporting. However, there is ample evidence of staff being forced to leave their organisations because they dared to speak out (3). Fostering a blameless reporting culture is a cornerstone of a caring organisation and is the starting point for obtaining accurate incident data.

What would you change or add to the template?

If you would like to comment here or respond in confidence about any aspect of this article, please feel free to post comments here or message me in private.

MRI Safety Matters? is hosting Kanal’s 3rd European MRSO/MRMD MRI Safety Training Course in London, 12th- 14th June, and a 2nd hybrid MRI Safety Update and Innovations Day in Edinburgh, 16th September.

1.Medicines and Healthcare products Regulatory Agency, the UK organisation tasked with ensuring the safety of both MRI as a medical device, and the associated equipment.

2. Official Journal of the European Union, Regulation (EU) 2017/745 of the European Parliament and of the Council 5 April 2017 on medical devices, amending Directive 2001/83/EC, Regulation (EC) No 178/2002 and Regulation (EC) No 1223/2009 and repealing Council Directives 90/385/EEC and 93/42/EEC, Statement no. 76

3.Stories of NHS Staff | A Better NHS; Nurse whistleblower who was wrongfully dismissed wins ￡460k payout | Nursing Times; NHS whistleblower Shyam Kumar wins case against regulator - BBC News