Patient Safety: Whose Job Is It Anyway? A Radiology Tragedy

As a Radiology Director, Administrator, Radiation Safety Officer and now owner of a medical imaging education company, I have always received numerous questions about job responsibilities, liabilities, and what job safety requirements are considered acceptable for every modality in medical imaging. I have witnessed and been involved in life altering incidents for patients. This begs the question; whose job is it anyway to ensure the patient’s safety?

On October 4, 2016, a 41-year-old MRI patient had an allergic reaction and cardiac arrest after the administration of the contrast gadolinium which led to life changing physical and mental consequences. There was no emergency drug box or crash cart in the MRI area.  The MRI suite was 63.5 feet away from the emergency room and an alarm was installed to notify personnel in the Emergency Department of an emergency in the MRI.  Unfortunately, no one in the ED recognized or knew what the alarm was or what the sound was supposed to mean. The assigned staff ED physician had no training about the MRI patients or the required safety aspects of treating emergencies in the MRI scanner area.  The rad tech who was injecting the patient recognized the patient was beginning a contrast reaction and yelled down the hall for the radiologist. The radiologist arrived in the MRI room, saw the patient, and ran to get an ED physician.

I wish I could say in court, under oath, that this was a circumstance that I had never seen before. I have seen it on multiple occasions where I have been in code situations and the radiologists could not perform CPR and were not even CPR certified. I have been in situations where CPR was implemented on patients who had DNR orders. I have been in situations where the wrong drug was administered or it was dripped at the wrong rate. All these situations were Adverse Sentinel events.

A recent comment was posted on social media describing the work situation of some MRI staff personnel who are working alone with no support or back up.  An outpatient MRI Center does some patients for the hospital next door and the hospital is a silent partner in the center. The never-present radiologist for the center only does interpretations for the outpatient exams but say the hospital radiologists or the ED physician will respond if there is any emergency such as a contrast reaction.  The hospital radiologist says that these patients are not his patients and refuses to acknowledge responsibility for care. The MRI technologists have a drug box but are not trained nor licensed to administer any of the drugs. They inject contrast at least once every day.

Again, we ask, whose job is it anyway?  In many circumstances, the patient with an altered status, contrast induced or not, will need transport to the emergency room. Outside the hospital the call must be made to a local EMS system for an ambulance and a wait for the paramedics to arrive. What do you do?  The 2020 ACR guidelines for MRI safety have addressed the professionally trained individuals that must be available to ensure patient safety.  The ACR requires 2 individuals with extensive guidelines for where these personnel must be located.  MRI facilities have been operational for many years, yet the number of MRI incidents just keep increasing. Now we have implemented a Magnetic Resonance Safety Officer (MRSO) and a MRMD, a radiologist who is responsible for the safety of the operation.

But wait! Since 2006 there has been software that would allow remote-controlled MRI exams performed over the internet.  The software is now installed and operational in several equipment manufacturers. I saw my first ad for a remote MRI technologist in 2020. The ad stated “The MRI technologist will be remotely operating the identified equipment at a hospital in another state but working in conjunction with a patient handler in the room of the hospital.”

The argument for a remote MRI technologist is that the experience level of the senior technologist should be shared with multiple facilities instead of a less experienced staff on the location.

Patient safety is an essential and vital component in the delivery of quality healthcare.  With a future that includes continuously advancing technology, artificial intelligence, teleradiology and the ability to send images through the internet at fantastic speeds, and in a system already prone to errors, the question must be answered.

Whose job is it anyway?

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.