December 08, 2015 | | Comments 0
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You know, I really find you quite attractive (human vs. technological magnetism)

Sometimes, particularly around the solstice, I struggle to come up with something (relatively) fresh upon which to pontificate—something that goes a little beyond the typical closing out of the safety year. Fortunately (at least for me; hopefully for you, the readers, as well), there have been enough funky things coming out of Joint Commission surveys this year to provide plenty of material. And today’s topic is the result of what appears to be an uptick in findings relating to MRI safety.

Now, the unfortunate aspect of all this is when the human and technological elements meet in combat, it would seem that it is the TJC surveyors that “win,” which is a very much less than desirable outcome.

At any rate, there’s certainly been a lot of information regarding safety in the MRI environment, first (and probably foremost) being the guidance provided by the American College of Radiologists (ACR). You can find lots of very good information on the topic on the ACR’s MR Safety page. And then, of course, our friends from Chicago felt this was important enough to warrant a Sentinel Event Alert (back in 2008…imagine that!).

Then, effective July 2015, we have the addition of two Elements of Performance (EC.02.01.01, EPs 14 and 16) dealing with some rather specific elements of MRI safety, particularly processes to ensure that folks who access the MRI restricted areas are educated/trained in MRI safety or screened by the folks controlling access to the restricted areas. I think we can reasonably point out that any time TJC adds EPs that indicate specific risks, etc., they are not convinced that hospitals well and truly have their collective acts together. And I guess, to a certain degree, they may have a point, but I think it may be more a question of managing behaviors than anything else (which I’m sure comes as a surprise to everyone in the studio audience).

Based on some TJC reports, the common theme that I’ve noted in recent survey seems to revolve around the management of surveyors when they trace patients into the MRI (and with the pervasive use of MRI in diagnostic medicine, I think I can safely say that if you have an MRI in your “house”, then there will be a patient tracer in to that environment), particularly as a function of screening the surveyors before they enter restricted areas. Now, part of me would like to craft a policy that requires a full screening (and yes, I am talking about a “full” full screening…hah!) of any and all regulatory surveyors—that might get them to shy away from being so obstreperous with these types of findings! That said, I think there is something to say about screening policies/protocols—make sure your MRI staff understand whatever screening process you’ve implemented, and (perhaps more importantly) prepare them for interactions with surveyors as a function of the screening process. Too many findings have come at the hands of surveyors that cited organizations for not having access that is “well controlled” or “adequately secured” based on MRI staff not putting the surveyors through the full screening process.

All that said, I would strongly encourage you to look at the process (and the policy, if you should happen to have a MRI screening/access control policy) for controlling access to the MRI restricted areas, including the mechanism for screening individuals (keeping in mind that “screening” can take different forms). EP 16, among other things, requires hospitals to restrict the access of everyone not trained in MRI safety or screened by staff trained in MRI safety from the scanner room (Zone IV, for those of you keeping score) and the area that immediately precedes the entrance to the MRI scanner room (typically Zone III). Now, you would think (and upon that thought, perhaps make an assumption) that The Joint Commission would provide some level of MRI safety training to their surveyors. That being the case, one could then have a process that does not require screening of the surveyors, based on their training in MRI safety. I think that MRI staff would need to specifically ask the surveyor if he or she had received MRI training before allowing the surveyor to proceed (and I guess the question for you folks in the audience would be whether you think the MRI staff would be comfortable asking the surveyor the question—it might be worth practicing). Even if the surveyor is in the company of folks from your organization that the MRI staff would “know” have been trained in this regard, is that enough to consider the risk as being appropriately managed—that sounds an awful lot like a risk assessment, if you ask me (yes, I know you didn’t, but you know I can’t resist invoking the mighty assessment).

So, it’s probably worth a concerted look during your end-of the-year surveillance activities (unless, of course, you’ve already done your second visit to the MRI this year, but may be worth a revisit); the sentinel event data published most recently by TJC ( provides no hard evidence (or at least hard, discernible evidence) that hospitals are not appropriately managing the risks associated with the MRI environment, but I think we could probably consider any sentinel event involving the magnet as something to be avoided (much like findings relating to MRI safety). If you have a solid process, then great. But if not, might be a good opportunity to harden that particular survey target.

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Filed Under: Environment of careHospital safetyThe Joint Commission


Steve MacArthur About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at

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