A gap in MRI safety

Another MRI accident has shed light on the lack of standardized safety protocols or an agency that oversees and enforces them, Fox 2 KTVU reported Sept. 9.

A wheelchair was brought into the MRI room by a trainee at a Mountain View, Calif., facility. When the machine was turned on, the wheelchair careened across the room, narrowly missing the patient inside. 

"My frustration comes out of the fact that these are almost 100% preventable through existing best practices," MRI safety expert, Tobias Gilk, told KTVU. There are standard practices and training for people who work in the MRI environment, but incident reportage is not standardized.

KTVU said they were given the runaround when trying to determine MRI reporting standards. The California Department of Public Health said that its radiological health branch was informed of the incident, but that the MRIs were outside their jurisdiction. It referred them to the California Medical Board, but it said to ask the health department because it does not "oversee these types of medical offices."

The outlet then reached out to the American College of Radiology who accredited the facility, but they said people can report incidents and accredited sites are subject to unannounced visits, but they do not "regulate" medical sites or require reporting of issues, failures or injuries. 

"I think that there's an obligation on the part of the state, in one form or another, to make sure that … the citizens of the state of California, when they go seeking healthcare, that they are assured some minimum levels of quality and safety," Mr. Gilk said.

MRI incidents and failures are on the rise, radiologists told KTVU, though it's to be expected as the number of MRIs being performed each year is rising.

Last year, a Kaiser Permanente hospital in California was fined $18,000 after an MRI machine's magnetic field pulled a metal bed to the machine and a nurse sustained serious injuries.

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