Online Program

Use of root cause analysis for incident prevention in the MRI environment

Wednesday, November 6, 2013 : 1:00 p.m. - 1:15 p.m.

Miriam Weil, MPH, ScD, Environmental Health and Safety, Boston Children's Hospital, Boston, MA
Hazel Ryerson, BS, Environmental Health and Safety, Boston Childrens Hospital, Boston, MA
Diane Biagiotti, BS, RT, Department Radiology MRI, Boston Childrens' Hospital, Boston, MA
Linda Poznauskis, BS, RT, Department of Radiology, Boston Childrens Hospital, Boston, MA
Amy Danehy, MD, Department of Radiology, Boston Childrens Hospital, Boston, MA
Howard Brightman, ScD, PE, CIH, CSP, Environmental Health & Safety, Boston Children's Hospital, Boston, MA
MRI scans use powerful magnets to create images. These magnets create a powerful magnetic field around the scanner which is contained in a protected room known as “Zone 4”. Ferromagnetic material that enters Zone 4 can become a projectile and be “pulled” into the scanner, sometimes with lethal results. Over the past 5 years, MRI use has increased at Boston Children's Hospital in three ways: patient volume, patient complexity, and magnet strength. These changes increase the probability of ferromagnetic material entering Zone 4. In 2011, two incidents with ferromagnetic projectiles demonstrated the need to improve the MRI safety program. This presentation describes our effort to use root cause analysis to understand and address the causes identified for each incident and near miss, thereby attempting to prevent the reoccurrence of this type of incident. Root causes were analyzed for 35 incidents and near misses over 18 months through use of fish-bone analyses of each incident with the individuals involved and creation of a scorecard that tracks all incidents and near misses by their root cause and helps identify trends. Three main causes were identified: Lack of standardization of screening process; Difficulty in obtaining important patient information prior to entering the scanner – e.g. implants; and distractions in the MRI Suite during the screening process.

Root cause analysis helped identify causal trends for the incidents and near misses. Interventions based on the root cause analyses were implemented to reduce the identified risks. The scorecard tracks how well the interventions are working.

Learning Areas:

Occupational health and safety

Learning Objectives:
Describe actions taken as a result of initial incidents. Describe how root cause analysis works and how it is being used to analyze incidents and near misses in the MR. Evaluate the effectivenss of root cause analysis in reducing incidents.

Keyword(s): Hospitals, Occupational Safety

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I have a doctorate in occupational safety and health. I am employed at Children's Hospital in Boston as Safety Coordinator working with the Radiation Safety and MR Safety Committees. This subject matter is something I am involved in intimately.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.