The questionnaire that was used in conjunction with the qualitative method content analysis provided credible results compared to previous studies. Moreover, new issues that were not specifically asked for emerged. The study should be repeated within a few years after educational efforts to investigate the impact of training intervention.
Incidents and background factors
In this study, staff at 13 MR sites were interviewed using a semi-structured questionnaire about the level of MR safety and MR-related incidents at their site. The reporting rate of incidents was very low (38%), suggesting that about 100 incidents remained unreported. In a recent report, it was suggested that about 30% of incidents were unreported and undocumented. In that web survey, the number of documented incidents was around 1.5 incidents per scanner and year , compared to 0.4 found here. Perhaps the different methods used to ask about the number of incidents, i.e. an anonymous web survey versus an in-depth interview, might affect the actual level of reporting.
In the FDA incident management system (MAUDE), RF burns are the most common type of incident (59% of all incidents, ). In this study, about 7% of incidents were reported as RF burns. Attitudes such as ‘Burns are to be expected once in a while’, implying it was felt unnecessary to report such incidents, suggest that some of the missing reports could have been RF burns. The willingness to report incidents varied widely across the sites. One site routinely reported scanned patients that later were found to have coins or paper clips in their clothing. This reflects an accurate interpretation of Swedish law that defines incidents as ‘Unwanted events that happened, or could have happened’ . Some sites did not report any unwanted events at all during the 5 years, something that may not be correct, and this could be an additional reason for the underreporting.
The most serious incidents were probably reported, but a few phenomena emerged that can be interpreted as reflecting an attitude toward MR safety. For example, it was said that RF burns are expected in MR, a few sites did not know the name of the incident reporting system, there were no reported incidents in 5 years in some sites and some sites were not able to search for MR incidents in the incident reporting system due to a lack of sufficient search features. To improve the safety culture in a clinical radiological context, actions such as education about the concept of ‘error prevention’ as well as methods for focusing attention to real incidents have previously been reported .
We did observe a negative correlation between ‘MR safety knowledge’ and the number of incidents, implying that more education is required. One contributing parameter could be that only 3% of the radiographers had an academic master’s degree or higher degree. This was also highlighted by the wish for more widely available safety training. If the MR operator’s knowledge about the motivation behind the questions in the screening forms was better, fewer patients would in our view likely be exposed to projectile accidents, or implant or bore-related RF burns. In Table 1, one site (#13) was recorded as 0% in ‘MR safety knowledge’, meaning that the lead MR radiographer did not think any of the MR operators would be knowledgeable enough to adjust commonly used safety-related scanning parameters such as SAR, SED or the effects of gradient performance. In-depth MR safety knowledge is important, and by improving knowledge about the influence of a number of scanning parameters, RF-related burns as well as implant malfunctions could perhaps be avoided. There are international organisations that provide various opportunities for education, including workshops and eLearning [13, 14], but those organisations were not mentioned in the interviews. Education in Swedish was asked for, but at present, there is no Swedish national body, or organisation, that can provide localised courses that would be as widely available as is requested. Clearly, improved means for mediating education need to be explored in future work.
There could be other obstacles to not reporting incidents apart from safety culture and lack of knowledge, such as complicated applications/software. Those obstacles did not occur in this material, but lack of time has been mentioned before .
Do staffing level and professional profile affect safety outcome? Here, the number of MR staff correlated with the number of incidents per year and per scanner, although only weakly so (Fig. 2, top left). We speculate that the division of work tasks might not be sufficiently well defined, so when several staff are working together, the MR safety is not fully covered, but when working alone, you are ‘the last man standing’. However, the more people who check the MR safety, the better it will be. International guidelines state that to be able to handle emergencies and to maintain MR safety at the site, there should be two staff members at a site with a single scanner [10, 14, 22] and at least three staff members in a dual scanner unit.
The MR personnel at some sites, for various reasons, cleaned the MR unit themselves. Other sites reported using external janitors, but they never left these workers unsupervised. The safety due to cleaning appeared to be high, and external janitors did not seem to affect MR safety in a negative way.
External personnel such as anaesthesia care teams typically contribute to an increased risk in the MR environment, as has been reported for example from Denmark . These personnel are required in some examinations, but education is particularly important for those who work more seldom in the MR scanner environment, ‘seldom’ meaning that the MR safety routines are much more difficult to maintain, and to keep the anaesthesia personnel group small appears to be essential from an MR safety perspective, although this is a huge challenge in large hospitals.
MR-specialised radiographers have a very diverse background, and not surprisingly, MR knowledge varied substantially across the sites. The entire process of maintaining MR safety requires collaboration between different professions such as radiographers, MR physicists and radiologists. In this study, MR knowledge increased as a consequence of the availability of MR physicists at the site, and that appeared to decrease the risk for incidents. Neither experience nor knowledge about MR safety of the radiologists was investigated in this study. Nevertheless, almost all radiographers were concerned about their radiologists’ MR safety knowledge. The need to educate radiologists more extensively in MR safety has also been confirmed by Rajan et al .
There seems to be a continued need and a wish for additional and more easily available MR safety education for all professionals working with MR. The guarantor could be either a national agency or a non-profit professional association. The hospital’s management must also prioritise this matter. We intend to repeat this survey every 3 to 5 years, perhaps expanding it to also include MR safety knowledge and attitudes among radiologists and physicists.
The main limitation of this study is the relatively limited number of formally documented incidents, and this resulted in relatively weak, but significant, correlations. The questionnaire was developed and evaluated by an MR safety expert committee, although it was not properly validated. Some of the questions have previously been used in a national survey , and by supplementing these with additional open questions, the responders were able to openly discuss their thoughts and opinions. One additional limitation was that only a few respondents were interviewed at each site. These individuals could have forgotten some of the events, or perhaps they simply were not aware of all incidents. However, they received the questionnaire beforehand, which hopefully reduced that risk.
This study showed that MR-related incidents are greatly underreported, and some of those incidents that actually do happen could potentially have catastrophic outcomes. To enhance the safety culture across all sites, more easily accessible education is needed. Broadening collaboration among radiographers, radiologists and MR physicists will also enhance the safety work.