Magnetic resonance imaging incidents are severely underreported: a finding in a multicentre interview survey

Abstract

Objectives: The purpose of this study was to develop a procedure to investigate the occurrence, character and causes of magnetic resonance (MR) imaging incidents.

Methods: A semi-structured questionnaire was developed containing details such as safety zones, examination complexity, staff MR knowledge, staff categories, and implementation of EU directive 2013/35. We focused on formally reported incidents that had occurred during 2014-2019, and unreported incidents during one year. Thirteen clinical MR units were visited, and the managing radiographer was interviewed. Open questions were analysed using conventionally adopted content analysis.

Results: Thirty-seven written reports for 5 years and an additional 12 oral reports for 1 year were analysed. Only 38% of the incidents were reported formally. Some of these incidents were catastrophic. Negative correlations were observed between the number of annual incidents (per scanner) and staff MR knowledge (Spearman's rho - 0.41, p < 0.05) as well as the number of MR physicists per scanner (- 0.48, p < 0.05). It was notable that only half of the sites had implemented the EU directive. Quotes like 'Burns are to be expected in MR' and not even knowing the name of the incident reporting system suggested an inadequate safety culture. Finally, there was a desire among staff for MR safety education.

Conclusions: MR-related incidents were greatly underreported, and some incidents could have had catastrophic outcomes. There is a great desire among radiographers to enhance the safety culture, but to achieve this, much more accessible education is required, as well as focused involvement of the management of the operations.

Key points: • Only one in three magnetic resonance-related incidents were reported. • Several magnetic resonance incidents could have led to catastrophic consequences. • Much increased knowledge about magnetic resonance safety is needed by radiologists and radiographers.

Keywords: Incident reporting; Magnetic resonance imaging; Medical device safety; Patient safety.

Fig. 1

Examples of MR accidents. In the top left corner (a), a trolley is stuck on the magnet. In the top right corner (b), a patient monitor is stuck on the magnet. In the lower left corner (c), a patient suffered a blister in the groin. In the lower right corner (d), safety zone II is missing (the red lines represent the three doors to the unit)

Fig. 2

Checklist for MR safety. A checklist lightly based on The Society for MR Radiographers & Technologists’ safety poster [13]

Fig. 3

Correlation graphs of some background factors for the incidents and MR safety knowledge of radiographers. Correlation between annual incidents per scanner with staff working with the scanner and staffing of physicists in the top row. In the bottom row, correlation between estimate of radiographer’s MR knowledge and examination complexity and staffing of MR physicists

Fig. 4

Implementation of EU directive. The responders answered the question concerning which year the Swedish law AFS 2016:3 (implementation of the EU directive 2013/35) was implemented at the site

Fig. 5

MR-specialised radiographers’ working time spent at an MR modality. Percentage of the 88 MR-specialised radiographers in 13 MR sites divided into groups according to the percentage of the total working time spent in their MR modalities