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The terrible accident in which a metal oxygen bottle introduced to an MRI room killed a child primarily was "a failure of hospital systems," according to the hospital’s investigation. The hospital’s report and public statements indicate that it is following the latest risk management advice to get to the process failures at the root of the accident rather than blaming individuals.
The fatal accident occurred recently at the Westchester Medical Center in Valhalla, NY. A 6-year-old boy was undergoing an MRI exam when the machine’s powerful magnet pulled a metal oxygen tank through the air and into the machine, fracturing his skull. Officials at the Westchester Medical Center said the tank had been brought into the exam room accidentally after the boy was already in the magnetic imaging machine and the 10-ton electromagnet was switched on. The county medical examiner’s office said the boy died of blunt force trauma, a fractured skull, and bruised brain.
The boy, who had undergone surgery before the MRI exam, was sedated when he was struck, says Edward A. Stolzenberg, president and CEO of Westchester Medical Center.
"As I have said before, this is more a failure of hospital systems than a failure of people," he says. "Part of accepting responsibility for this by the Medical Center is the promise to all our patients, visitors, and staff that patient safety is the No. 1 priority. We have made 32 safety changes in the last few weeks and have asked the leading national expert in MRI safety to come here . . . and review our work."
Emanuel Kanal, MD, of the University of Pittsburgh Medical Center, was scheduled to spend a day at Westchester offering his opinions and meeting with staff. The hospital also initiated a national review of MRI patient safety by persuading the American College of Radiology (ACR) to create a Blue Ribbon Panel on MRI Safety to establish the first-ever set of accepted guidelines, policies, and recommendations for safe MRI practice. The ACR has responded by scheduling a conference on the issue this month in Reston, VA.
"An accident of this kind could have happened at any hospital or radiology facility in the U.S. and could still happen even today," Stolzenberg says. "We are working tirelessly to prevent this tragedy from happening anywhere, ever again."
Stolzenberg says MRI manufacturers have reported that oxygen tanks and other metal objects are removed from MRI magnets around the nation at least every other week. He noted that during the week of July 30, immediately after the MRI accident, Westchester bought the last two MRI-compatible (nonmagnetic) mechanical respirators and fire extinguishers from the nation’s largest distributor. Magmedix, of Gardner, MA, reports that every hospital and MRI facility in the country is buying up such nonmagnetic supplies at an unprecedented rate. The company has been inundated with calls and purchase orders for these products.
In another sign that the health care industry is taking notice of MRI hazards, the nonprofit research agency ECRI has issued a hazard report and recommendations for MRI safety. ECRI reports that a wide range of objects have been drawn into MRIs, including IV poles, parts of a forklift, a helium cylinder, a mop bucket, a laundry cart, a chair, a ladder, a patient lift, a light fixture, a floor buffer, a pulse oximeter transformer, tools, scissors, and traction weights.
However, ECRI says the incident at Westchester Medical Center appears to be the first death directly caused by an object being drawn into an MRI. ECRI experts say the most important recommendation is to make sure that someone is responsible for safety. That person needs to establish safety policies and procedures, as well as personally ensuring that nothing improper is brought into the MRI room.
Among its 14 recommendations, ECRI advises that all personnel who enter the MRI room receive formal safety training and that they always assume that a magnetic field is present. In addition, areas where the magnetic field exceeds 5 G should have restricted access for personnel and equipment. There should also be a list of MRI-safe equipment, and patients, staff, and equipment should be screened for magnetic objects before entering the MRI room.
Stolzenberg says there was a similar incident at the hospital in 1997 when an oxygen tank was introduced into the magnetic field. There was no patient in the MRI at the time. The Westchester CEO says the hospital has taken immediate steps to improve MRI practices. These are some of the changes:
• purchasing and using only nonferrous oxygen cylinders, fire extinguishers, and other supplies;
• increasing the safety zone around the MRI machine;
• adding new warning signs and physical markers to identify and secure the area;
• removing the door to the control room to minimize obstacles in responding to patient care or staff needs;
• enhancing the intercom system between the control room and the MRI scanning room;
• new comprehensive programs for ongoing inservice training for MRI and non-MRI staff;
• overhauling the safety orientation for MRI patients and contract service workers, such as ambulance drivers.
The Westchester’s incident review report obtained by Healthcare Risk Management reveals that the tragedy began with an attempt to provide adequate oxygen to the patient during the MRI exam. These excerpts from the report outline the sequence of events:
• "Immediately prior to beginning the actual filming, the anesthesiologist attempted to turn up the oxygen flow . . . without any success. As there was no direct microphone communication between the MRI technologist and the anesthesiologist, the anesthesiologist knocked on the window between the MRI room and the console room to get the technologist’s attention. The technologist responded by leaving the console room and going to the door of the MRI room. The anesthesiologist informed the technologist he had no oxygen. The technologist left the MRI room, walked through the console room into the computer room (which is the location of the oxygen flow into the MRI room). A second technologist who was in the console room at the time accompanied the first technologist into the computer room to assist in addressing the oxygen supply."
• "A nurse preparing to leave the MRI suite was passing the MRI door, which she observed to be wide open, saw and heard the anesthesiologist. In response to the apparent urgency of his concern the nurse noticed two [oxygen] cylinders in a handcart on the floor in the patient care alcove across the hall from the door of the MRI. She recalls one was empty and one was full. The nurse recalls lifting the cylinder by the regulator and transferring it to the anesthesiologist."
• "The oxygen cylinder was introduced into the magnetic field surrounding the MRI and was immediately drawn to the core of the magnet causing head trauma to the patient."
• "The nurse recalls that the anesthesiologist took the oxygen cylinder from her while she was in the hallway. She states she is not certain as to how many inches or feet he may have been from the inside of the MRI or out of the doorway."
• "The anesthesiologist recalls that a nurse brought the cylinder into the MRI room. As it was being drawn into the bore of the magnet he tried to catch it, but could not."
The incident review could form the basis for a root cause analysis if the incident is reported as a sentinel event. The document is divided into five basic issues: Systems, Human Resources, Environment of Care, Information Management, and Other Factors. The review of the incident concluded that these were the critical factors associated with the delivery of oxygen to a patient undergoing MRI:
• A poorly designed oxygen delivery and monitoring system that failed to ensure the continuous delivery of oxygen and deprived the attending anesthesiologist of the means to both determine the availability of oxygen and switch sources without assistance.
• Ineffective communication systems impeded the anesthesiologist’s attempts to communicate his concern for the patient’s safety to the others in the MRI suite and to monitor their efforts to assist him.
• The storage of MRI-incompatible material in the MRI Suite.
• The failure to safely identify and safely secure the restricted magnetic field area.
• Ineffective education of both hospital and nonhospital staff regarding the dangers associated with MRI magnetic fields.
• Absence of and incomplete written policies and procedures related to the provision of oxygen in MRI. (See "Systematic problems led to MRI accident," for more on systemic deficiencies identified in the report.)
Stolzenberg emphasizes that "the hospital accepts full responsibility for this terrible tragedy" and says media accounts focusing on the nurse who actually introduced the oxygen tank to the room are not productive. The individual would not have been able to make such a mistake without deficiencies in the hospital’s policies and procedures, he says.