Rates of safety incident reporting in MRI in a large academic medical center.
OBJECTIVE
To describe our multiyear experience in incident reporting related to magnetic resonance imaging (MRI) in a large academic medical center.


METHODS
This was an Institutional Review Board (IRB)-approved, Health Insurance Portability and Accountability Act (HIPAA)-compliant study. Incident report data were collected during the study period from April 2006 to September 2012. The incident reports filed during the study period were searched for all reports related to MRI. Incident reports were classified with regard to the patient type (inpatient vs. outpatient), primary reason for the incident report, and the severity of patient harm resulting from the incident.


RESULTS
A total of 362,090 MRI exams were performed during the study period, resulting in 1290 MRI-related incident reports. The rate of incident reporting was 0.35% (1290/362,090). MRI-related incident reporting was significantly higher in inpatients compared to outpatients (0.74% [369/49,801] vs. 0.29% [921/312,288], P < 0.001). The most common reason for incident reporting was diagnostic test orders (31.5%, 406/1290), followed by adverse drug reactions (19.1%, 247/1290) and medication/IV safety (14.3%, 185/1290). Approximately 39.6% (509/1290) of reports were associated with no patient harm and did not affect the patient, followed by no patient harm but did affect the patient (35.8%, 460/1290), temporary or minor patient harm (23.9%, 307/1290), permanent or major patient harm (0.6%, 8/1290) and patient death (0.2%, 2/1290).


CONCLUSIONS
MRI-related incident reports are relatively infrequent, occur at significantly higher rates in inpatients, and usually do not result in patient harm. Diagnostic test orders, adverse drug reactions, and medication/IV safety were the most frequent safety incidents.
Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
Mohammad
M
Mansouri
Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
Shima
S
Aran
Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
Harlan B
HB
Harvey
Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
Khalid W
KW
Shaqdan
Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
Hani H
HH
Abujudeh
D000046:Academic Medical Centers / Q000706:statistics & numerical data; D003625:Data Collection; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000009:adverse effects*; D019300:Medical Errors / Q000706:statistics & numerical data*; D061214:Patient Safety; D011871:Radiology / Q000706:statistics & numerical data*; D011872:Radiology Department, Hospital; D015203:Reproducibility of Results; D012189:Retrospective Studies; D062606:Tertiary Care Centers / Q000706:statistics & numerical data
MRI safety; incident report; patient safety; quality and safety; safety incident reporting system; safety report