Prevalence of Unanticipated Events Associated With MRI Examinations: A Benchmark for MRI Quality, Safety, and Patient Experience

Abstract

Purpose: To determine the prevalence of unanticipated events (UE) associated with MRI examinations in a multicenter academic radiology department.

Methods: UE reported by MRI technologists for examinations performed between June 2013 and November 2014 on 17 scanners in a university- and community-affiliated single health system were retrospectively reviewed. Events were categorized into the following categories: (1) problems with orders and scheduling; (2) scan delays; (3) unanticipated foreign bodies; (4) non-contrast-related patient events (eg, patient motion, discomfort, claustrophobia, need for sedation); (5) contrast-related patient events; and (6) technical acquisition issues. Logistic regression analysis of UE was performed after adjusting based on scanner site (university- vs community-affiliated hospital), hospital setting (outpatient [OP] vs mixed outpatient and inpatient [OP/IP]), and timing of the scan (business days vs weekends/holidays).

Results: A total of 34,587 MRI examinations were assessed (87% university-affiliated; 58% OP) with 5775 (16.7%) UE (1.9% of patients had more than one category event). Rates of UE for each category were as follows: 1.9% orders and scheduling, 3.3% delays in scan, 0.5% foreign bodies, 10.4% non-contrast-related patient events, 1.3% contrast-related patient events, and 1.5% technical issues. After adjustment for location of scanner, clinical setting, and timing of the scan, the rate of overall UE was significantly higher in university-affiliated sites (coefficient, 0.09 [95% confidence interval (CI), 0.07-0.10]; P < .001), in scans performed in the mixed OP/IP setting (coefficient, 0.09 [95% CI, 0.08-0.09]; P < .001), and in scans performed during weekends/holidays (coefficient, 0.02 [95% CI, 0.01-0.04]; P < .001).

Conclusions: UE associated with MRI examinations are common (16.7%), with the majority being patient-related issues unrelated to contrast administration.

Keywords: MRI; The Joint Commission; Unanticipated events; benchmarking; quality; safety.