Keywords:
MR physics, Cardiac, MR, Education, Safety
Authors:
P. Gilligan, P. Cooper, C. Nolan, J. Bisset, C. McEntee, S. Maguire, B. Emerson, J. Galvin, J. G. Murray; Dublin/IE
DOI:
10.1594/ecr2018/C-0969
Conclusion
Discussion
The outcome of the FMEA has improved understanding of the high risk areas in our scanning process and led to actions being taken to enhance MRI safety for this patient cohort.
Residual risk exists in terms of patients or staff being uneducated about the risks of MRI scanning on patients who have ICDs or pacemakers.
Since undertaking this FMEA,
staff education sessions have begun and the FMEA has been presented at the radiation safety meeting.
As part of CPD session to radiographers ,
lectures on cardiac devices and the FMEA were presented.
The FMEA has been presented at departmental radiology and cardiology meetings,
quality meetings in the hospital,
the hospitals Patient Safety Week and highlighted in the Quality staff newsletter.
After the recommendations of the group were implemented ,
The risk priority number decreased from 1426 to 658.
The lower risk meant that the MRI department could clear the backlog of cases with implanted devices and take on new cases more efficiently with a higher safety profile.
Indeed an incident was picked up on site where the device failed to reset properly and an appropriate care plan was put in place. During examination of the process a number of ancillary improvements were identified which have initiated further quality improvements:
1. Improved patient screening MRI questionnaire with accurate risk information and diagram to prompt patient/carer regarding implementation.
2. Requirement to simulate cardiac arrest which led to improvements around facilitating rapid egress by leaving MR compatible trolley in the room and locating the mri assistant in the MR suite to facilitate emergency response.
3. Improved easy to read MR Signs such as MRI scanner always on,
from the UK physics group
The FMEA also led to stronger links between cardiology and radiology which benefits effective communication on many levels.
The model may be useful in assessing the risk associated with implanted cardiac devices in other areas such as radiotherapy and CT scanning.
In May 2017 the heart rhythm society produced a useful consensus statement ( see ref.
7 below).
More recent publications5 underpin the findings of the revised workflow presented here in terms of the requirement for monitoring of device function by expert staff.
Conclusion:
Failure Mode error analysis has been a useful tool in a highly technical multistep process and has facilitated safer MRI scanning of implanted devices.