Robertson, with Metrasens, echoes Gilk’s assessment and says the same inattention is also directed at projectile incidents, the second-most common type of adverse event in the MR environment. Another issue that contributes to this inattention he clarifies is the fact that physicians mainly only focus on incidents that involve patients rather than all MR-related incidents in general.

“It is generally acknowledged in the community that only a very small proportion of projectile incidents are actually reported,” says Robertson. “If it is a patient injury, a patient adverse event, generally those things are reported.”


The lack of focus in these areas is rooted in the protocols and guidelines handed down from senior staffers to new generations, many of which focus on the use of medical equipment and the effects they can produce in MR environments rather than outlining the specific causes of adverse events and the degree of attention they each require.

Gilk believes the issue of implants should continue to be studied extensively, but not at the cost of other areas of MRs. He asserts that the best option is to research and identify the aspects of MR environments that are leading to adverse events and how we can use our resources to prevent them.



“There hasn't been a very effective, contemporary effort to ask, 'OK, how are we injuring patients? What are the mechanisms that we could deploy that could reduce or eliminate those types of injuries,’ " he says. “[Accident] prevention really needs to begin with an understanding of how these injuries occur in the first place and what the frequency and the severity of different injury types are that we can begin to weigh the risks and benefits of spending a finite amount of resources that a provider has.”

Safety at what cost?
In the last 10 to 15 years, MR has become a common tool for examining high-acuity patients. This places a bigger burden on insurance companies to cover MR exams more frequently and for more patients.

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