MR Safety Week 2017

MRI Safety and the Story of a Medication Patch

A technologist familiar with the events has provided the following incident for educational use during MR Safety Week. The site has chosen to remain anonymous but many of us have had similar events over the years. We can all learn from these events and continue to improve our safety culture.

Details about what transpired:  A MRI was scheduled to be performed on an alert inpatient.  The initial patient screening form was done on the patient floor by nursing, indicating that (s) he did not have a medication patch.  When the patient arrived at the MRI department the technologist followed the site’s standard procedure of reviewing the form with the patient, discussing and researching implants, as well as a brief physical inspection.  After the scan the patient informed the technologist of pain. The technologist investigated the area and noticed a Nicotine patch not noted on the form nor discussed at any time during the screening process.  The patch had resulted in a blister forming on the upper arm.

Remediation efforts by the site: The site reviewed its screening policies as well as the nurse’s role in screening and its impact on patient safety.  As a result, for inpatients, nursing initiates the documentation on the MRI Screening form.  The technologist will receive this form after nursing has reviewed it with the patient and discusses items such as EKG leads, IV pumps, and medications with the nurse.  A more streamlined form of communication using the EMR was also developed.

Reported: I can say with certainty that an incident/safety report was filed.

Lessons Learned: Nursing plays a vital role in MRI safety screening documentation.  Technologist and nursing staff are responsible for identifying and removing, with referring MD approval, medication patches prior to the MRI.

The second lesson learned is the importance of a streamlined form of communication and understanding of responsibilities between nursing staff and technologists. The new electronic form is printed as needed and includes medication patch removal.

Patients may not remember to report medication patches. Technologist and MR support staff must remain vigilant and screen both visually and orally.  Communicate well and often.

To summarize:

  1. Confirm medication patches are on both your pre-screening and on-site screening forms. Check the medical records if they exist. Discuss with your patients.
  2. Never remove a medication patch without referring MD approval. There are real dangers when patients lose access to necessary medication.
  3. There is also a danger of accidental overdose when a patch heats.
  4. Review your communication and documentation procedures.
  5. Report MR Safety incidents to your supervisor. Your institution should submit any adverse event reports to the FDA MAUDE database.

The websites below are interesting reads and have a wealth of useful information.