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

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.