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BMJ Quality Improvement Report
Using near-miss events to improve MRI safety in a large academic centre
  1. Nirvani Goolsarran1,
  2. Jose Martinez2,
  3. Christine Garcia3
  1. 1Department of Internal Medicine, Stony Brook University Hospital, Stony Brook, New York, USA
  2. 2NYU Langone Health, New York, New York, USA
  3. 3Department of Medicine, University of Pittsburgh Department of Medicine, Pittsburgh, Pennsylvania, USA
  1. Correspondence to Dr Nirvani Goolsarran; nirvani.goolsarran{at}stonybrookmedicine.edu

Abstract

Near-miss events represent an opportunity to identify and correct errors that jeopardise patient safety. The MRI environment poses potential safety threats and is frequently associated with near misses or adverse events related to improper safety screening for presence of cardiac pacemakers and other potential contraindications. At our institution, MRI safety screening lacked a formalised structure and standardisation; the process relied on a single-step safety screening process. As a result, we observed a significant number of near misses associated with improper MRI screening that resulted in ‘close calls’ in patients with incompatible metals implants. The purpose of this project was to use a quality improvement approach to analyse the near-miss pattern and create a multistep intervention to decrease the number of near misses associated with MRI screening and to ultimately decrease the potential for patient harm. Using the Plan-Do-Study-Act model, we decreased the number of MRI near misses from 22 to zero near misses in 1 year after implementation. The project demonstrates successful transformation of near misses to a never event: a reportable event that should never happen. The project also demonstrates the importance in targeting and prioritising a pattern of near misses, which are unplanned events that do not result in injury but had great potential to do so.

  • quality improvement
  • patient safety
  • near miss

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjoq-2018-000593

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    Footnotes

    • Contributors NG was responsible for the overall content of the manuscript, she conceptualised the design and drafted the original manuscript. JM monitored and tracked the data, and designed the results of the study. CG revised and edited the final version of the manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient and public involvement statement Data was collected in de-identified fashion therfore patient consent was not necessary for the project. The Institute Review Board approved the project as exempt without the need for patient consent

    • Patient consent for publication Not required.

    • Ethics approval The Institutional Review Board at Stony Brook University Hospital, NY deemed this study as exempt as an educational initiative. IRB acknowledgement # 717726-1.

    • Provenance and peer review Not commissioned; externally peer reviewed.