Safety: First, Do No Harm

Abstract

If you plan on having anything to do with MRI, you had better care about safety. Whereas MRI is a powerful diagnostic tool that has become indispensable in health care delivery, it is potentially a double-edged sword. Patients have literally lost their lives due to errors in the use of clinical MRI scanners, and others have been seriously injured. Although the safety issues surrounding MRI have been know since its inception, renewed interest and serious attention to MRI safety dates from summer 2001. In July of that year, a 6-year-old boy who had just recovered from curative surgery for a brain tumor was killed during a follow-up MRI scan. During the scan, a ferromagnetic oxygen tank was brought into the scanner room and it launched into the bore crushing the little boy’s head. This event received international media attention and instigated the American College of Radiology (ACR) to convene a Blue Ribbon Commission to assess the state of MR Safety and the scope of safe MRI practice. The commission published a White Paper on MRI Safety, which has been updated since its initial release (see Appendix 4 for the complete citations), delineating, in considerable detail, the parameters of safe MRI practice. The ACR White Papers are required reading for anyone involved in MRI and especially for physicians responsible for the safe operation of an MRI facility. If the urge to do good by patients does not suffice to encourage compliance and attention to detail, the fact that such policy papers are likely to form de facto standards used in litigation should help us all wake up and pay attention.