Purpose or Case Report: In 2016, we focused on MRI safety and the inherent cultural barriers to reduce the risk of undetected or misplaced metal objects causing MRI accidents. We successfully addressed this opportunity using a coordinated approach with Patient Safety, Performance Improvement and Radiology Leadership to provide a multi-faceted solution.
Despite implementation of ferromagnetic detection systems (FMDS) technology, numerous gaps in screening effectiveness were identified. Three primary improvement objectives were established involving place, people and process leading to 42 new practice changes that were implemented, and 68 existing process improvements instituted. Alarm fatigue was one among many identified risks. Variables included the physical location of the projectile on the transport person, as well as the horizontal or vertical orientation of potential hazard while being carried were identified during a series of nine standardized PDSA testing sessions that were completed in the clinical setting.
Methods & Materials: A series of ten standardized PDSA testing sessions were completed in the clinical setting and included the use of a pre-screened ferrous-free person who transported a “control” projectile through the FMDS at separate intervals. The control consisted of either a 4.5” straight scissors or a 5” curved forceps divided into two groups; exposed and non-exposed. All controls were deemed a “projectile hazard”, according to the ASTM deflection test (Ref).
Results: Significant gaps in effectiveness and programmatic variables were identified within the expected performance of the FMDS installed. With the current settings and modifications made, we discovered a gap that exists at the center region of each door passageway where detection was minimal.
Through our project, 42 new practice changes were implemented and 68 existing process improvements were achieved. A 78% reduction in alarm rates was achieved and a 100% reduction of incidents where hazardous projectiles entered zone IV was realized. These reductions were achieved via optimization and customization of the latest FMDS technology and various process changes and improvements.
Conclusions: Institutions where these devices have been installed may not be able to reliably detect metallic objects classified as projectile hazards. Validation of installed systems can and should be accomplished in order to optimize the level of sensitivity and effectiveness of each FMDS installed in situ.