Hudson Darren, Jones Andrew P
InHealth Group, Buckinghamshire, UK.
Christie Medical Physics and Engineering, The Christie NHS Trust, Manchester, UK.
BJR Open. 2019 Apr 30;1(1):20180006. doi: 10.1259/bjro.20180006. eCollection 2019.
A review of MRI safety incidents conducted over a 3-year period for a large independent sector diagnostic imaging provider in the UK. The review took a systematic approach using reports logged on an internal incident reporting system that were then categorised and analysed for themes and trends. Notable cases and actions taken are also described from within the period. MRI safety-related events made up 7.5% of the total number of incident reports submitted and 15.5% of all MRI-related reports. The MR safety-related incidence report rate was 0.05% (1 per 1987 patients), which is relatively low considering the number of patients seen in our facilities each day. Internal MRI safety events indicated the main trends to be around referral of contraindicated devices (32% of reports) and failure in the screening process (21.5%-either due to unexpected implants or being unable to confirm safety). To improve practice and work to reduce incidents, advice and instructional materials were developed. The review suggests a potential approach to categorisation of MRI-related safety events which could allow comparisons to be made across organisations, helping to look for trends and guide learning. It also provides insight into the state of MRI safety within the organisation, a rationale for some of the interventions introduced to improve safety, and discussion around common issues arising in MRI safety.
对英国一家大型独立部门诊断成像提供商在3年期间发生的MRI安全事件进行的审查。该审查采用系统方法，利用登录到内部事件报告系统的报告，然后对这些报告进行分类，并分析其主题和趋势。还描述了该期间内的显著案例及采取的行动。与MRI安全相关的事件占提交的事件报告总数的7.5%，占所有与MRI相关报告的15.5%。与MR安全相关的发病率报告率为0.05%（每1987名患者中有1例），考虑到我们机构每天接待的患者数量，这一比例相对较低。内部MRI安全事件表明主要趋势围绕禁忌设备的转诊（报告的32%）和筛查过程中的失败（21.5%，原因要么是意外植入物，要么是无法确认安全性）。为了改进实践并努力减少事件，制定了建议和指导材料。该审查提出了一种对MRI相关安全事件进行分类的潜在方法，这可以使各组织之间进行比较，有助于寻找趋势并指导学习。它还深入了解了该组织内MRI安全的状况、为提高安全性而采取的一些干预措施的基本原理，以及围绕MRI安全中出现的常见问题的讨论。
