This case was first reported in our blog “Patient Safety: Whose Job Is It Anyway? A Radiology Tragedy” in September 2020.  The case involved an allergic reaction to gadolinium by a 41 year old patient. Immediate hypersensitivity reactions to gadolinium are not common, but in hypersensitive patients repeated reactions average approximately 30%.

Adverse events to contrast media can be categorized into time frames and the severity of reactions, but not much research has occurred on the incidence and risk factors of immediate hypersensitivity reactions to MR contrast media. Reactions including anaphylaxis have been reported and the increase in MR utilization has increased reactions accordingly.  New safety recommendations from The Joint Commission and the American College of Radiology address safety concerns for contrast media, scheduling, personnel, department layout and signage among other important issues.  From social media reports, MRI facilities are slow to implement these safety programs.

This case highlights what we know about any foreign substance injected into a diagnostic imaging patient. You must be prepared for adverse events. You are never safe, and all imaging, emergency, and code teams should be on the same page for emergency response.  This parallels training the local fire and EMS personnel in your city, region, or area must receive to keep everyone safe.

The jury brought back a unanimous verdict in favor of this patient and assigned a large portion of the award for his continuous lifetime care expected to span the next three decades. The remainder of the award was designated for medical expenses, lost earnings and for pain and suffering. The jury only took 2.5 hours of deliberation before the verdict. The jury assigned 25 percent of the award to the radiologist and 75 percent to the hospital.

This has alleviated some concerns for the family but does not compensate for the fact that this young man arrived for a MR procedure for low back pain and experienced a cardiac arrest which deprived his brain of oxygen for too long. The final result was a brain injury that left him with the mental acuity of a young child.

It is almost impossible to predict who will have these hypersensitive events, but we do know that we must be prepared “for when not if” it happens to us.