A child, rushed to the ER following a serious roadside accident, was assessed by doctors who determined an MR scan was in order.

But as the child entered the MR environment, a ferromagnetic detector went off, alerting staff that the child was carrying a metal object of some type. Upon finding no object on the outside of the child’s body, the staff determined that the child must have an implant.

Sure enough, the patient had been implanted with a programmable shunt, a procedure that neither the physician nor the staff was aware of. And while the doctor pressed for the operation to still go ahead as planned, the MR technologist refused.
“The technologist knew the information and preventing the child from going into the MR exam certainly prevented potentially a very injurious situation for that child,” Colin Robertson, the senior vice president of sales and marketing at Metrasens, a manufacturer of ferromagnetic detectors, told HealthCare Business News.

The detector going off and the doctor and technologist communicating their views and coming to a decision on how to proceed are good examples of how MR safety is supposed to work.

Yet, according to experts, the rate of MR adverse events increased by 500 percent from 2000 to 2009, a rate troublingly disproportionate to the 114 percent increase in overall scan volume.

What is the cause of these safety issues that put patients in danger at the point of care? The reasons are up for debate, though experts can agree on one thing: the rise in adverse events in MR rooms is a consequence of people making poor decisions.

Burns, projectiles and implants
Two-thirds of MR adverse events, excluding the presence of pharmaceuticals, pertain to burns. Yet, experts like Tobias Gilk, the chairman of the American Board of MR Safety and an MR safety trainer, say that researchers in this field do not devote nearly enough attention to this issue.

“If you ask MR departmental staffers what they spend the most time on in MR safety efforts,” Gilk told HealthCare Business News, “it’s on implant and device safety which is tremendously important but if you contrast the amount of energy spent on implant and device safety, identifying what the implant is, trying to find the manufacturer information, trying to make sure that that manufacturer information actually works with your MR system, that just eats up hours and hours of productivity for MR providers on a regular basis. Burns typically receive a very small minority of time, energy and attention at the point of care.”

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