Sounds like it could happen.
http://www.imrser.org/PDF/JMRI.2004.colletti.pdf
August 2005
Four Years After The Tragedy:
The Wake Of An MRI Death.
By Robert Junk, AIA, AHRA and Tobias Gilk
Building codes, JCAHO requirements, architectural guidelines, ACR design standards, insuror credentialing / privileging processes... in the four years following the death of Michael Colombini, which of these hasn't implemented requirements for MRI patient safety in facility design for new magnetic resonance imaging facilities? Which of these groups, each charged with the safety and welfare of patients and the public, has failed to require facility safety standards for MRI suites in the last four years? Would you believe, all of them? The ACR has published its recommended 4-zone screening protocol, but it is not a requirement. And in it's 2004 update to the 2002 White Paper on MR Safety, the ACR stepped back from making any facility guidelines.
Four years ago, six-year-old Michael Colombini was receiving a post-operative MRI to verify that the neurosurgeons had been successful in removing a brain tumor. He may have been relieved that the surgery was over, or may have been thinking about the cool stories he could tell his first-grade classmates about the new scar on his head. Whatever he was thinking prior to that MRI, he probably thought that the worst was behind him.
According to both hospital and state reports, young Michael began having difficulty breathing while receiving that scan, so the anesthesiologist tried to give the boy supplemental oxygen. The medical oxygen that was piped into the MRI room wasn't part of the hospital's main system, but rather an independent storage cylinder and something was apparently wrong with the supply. Michael wasn't getting the oxygen he needed.
The MRI's oxygen system wasn't tied into the hospital's central alarm system, so nobody outside the MRI suite was immediately aware that there was even a problem. When the gas supply failed, both of the technologists on duty left the console to try and resolve the problem, leaving the access to the magnet room unattended by trained MR staff. The anesthesiologist, in the magnet room with the boy, was screaming for oxygen. As the level of panic escalated, a hospital staffer came into the MRI suite and noticed that there was a portable oxygen cylinder in the control room. That steel cylinder was brought into the magnet room where the MRI pulled it from the grip of whoever was carrying it and thrust it into the bore of the magnet, where the boy was at the time.
We all know how this story ends... the cylinder hit the boy in the head and he died from the injury.
Westchester Regional Medical Center was fined $22,000 by the State of New York, and they, the anesthesiologist, GE Medical Systems (now GE Healthcare) and the MRI service contractor are embroiled in a lawsuit that is still playing out.
And today, there are still MRI facilities with patchwork medical gas services. Some continue the prohibited (and dangerous) practice of snaking a length of tube through a waveguide in the control room wall, feeding oxygen to patients in the bore from a remote portable oxygen cylinder. Modular buildings for MRI continue to be plunked-down with independent services, as if they were their own little hospitals, some without centralized alarming systems. Haven't we learned from these mistakes?
The fact that MRI's attract steel cylinders is not news to anyone who has spent any time working around MRI. Why on Earth would there have been a portable steel cylinder immediately outside the magnet room? Even today hospitals continue to transport, store and accumulate unsafe materials in areas immediately outside magnet rooms! That cylinder missile incidents continue at MRI facilities on a regular basis isn't a testament to their inevitability, rather to our failure to implement the screening protocols that are out there.
That a hospital staffer could come into the MRI suite and get access to the steel cylinder points out the absence of effective access controls to the MRI suite. Why was the only substantive safety provision of the suite the presence of the technologists? And three years after the ACR White Paper on MR Safety, why is it that MR suites continue to be designed and built without the four-zone screening and access-control provisions?
Operationally, there were clearly failings that don't directly correspond to the design and construction of the facility. What MR-Safety training did the anesthesiologist have? Why did both techs leave the area? If the boy was coding, why wasn't he removed from the magnet room before attempting to treat him?
This tragedy resulted from a chain of events. By interrupting just one of these contributing factors, it might have been possible to prevent this death. We can train our staff and hope that they recall those lessons when the timing is critical, but human behavior is hard to predict. Perhaps the anesthesiologist had extensive MR safety training, but his clinical training which told him to establish that airway dictated his behavior that day. If human behavior is so variable, then what can we do to improve patient safety? The answer is, we can build it into our MRI facilities.
We have the information in front of us, in the form of the ACR White Paper on MR Safety. We can build a suite to support the screening protocols. We can create quarantine areas away from the magnet room to store unsafe ferrous materials. We can build-in access-controls to our suites. We can do a better job with the design of medical gas systems. Any one of these might have prevented this tragic accident, and certainly all of them would have made a difference.
We don't mean to suggest that facility safety is the only component to MR safety. We view MRI safety as a tripod, supported by clinical safety (device safety, clinical procedures, etc...), operational safety (patient and device screening, staff training, etc...), and facility safety (access controls, screening support, etc...). It is clear, however, that facility safety is infrequently analyzed and irregularly applied.
Without guidance from the professional and regulatory bodies with influence in MRI, the patchwork nature of facility safety will continue and, with the profound growth in industry utilization and magnet strengths, it may only be a matter of time before someone else dies in a similar MRI accident.
To avoid having your facility fall short on MRI safety, be sure to engage an architectural consultant that specializes in MRI suite design. MRI consultant fees range from less than $4,000 for a safety peer review to less than 1% of the overall equipment cost for full consulting services on an equipment upgrade.
--------------------------------------------------------------------------------
To learn more about how to MRI suite designs can improve both patient safety and throughput, contact Junk Architects at (816) 472-7722.
Click here to return to the main newsletter page.
