Table 5. .

Summary of example alerts arising from the incident management programme

Alert	Event	Root cause	Outcome
1.	A near-miss occurred when the safety checking processes failed and the patient, who had a cardiac pacemaker in situ, was taken into the scan room. This was detected by the MR Supervisor at the last minute who removed the patient before they were placed within the magnet.	Poor In-Team Communications causing confusion around team roles due to too many staff involved in the care of the patient.	Alert sent to remind staff that whilst trainee and support staff can assist patients with form completion and provide a preliminary assessment of safety, ultimate accountability falls to the MRI Radiographers working in and supervising that Controlled Access Area at the time. Trainees and support staff should be aware of the limits of their scope of practice and delineation of roles and responsibilities should be clearly outlined locally, along with the overall Operational Policies.Introduction of an adapted “Have you PAUSED and checked” based on the Society of Radiographer’s campaign to act as aide memoire for staff when dealing with patients to ensure all suitable checked are carried out throughout the examination.
2.	A patient was unknowingly scanned with an unknown aneurysm clip in situ before being recognised on scans and removed from the scanner.	Lack of recall despite multiple protective screening barriers. The GP did not highlight the patient history nor did the patient recall any surgery. When the patient did recall surgery on the day she was still unaware of the clip in situ. Demonstrating the potential issues when relying on human memory and necessity of screening patients multiple times with different wording.	The safety screening form, whilst not intended to be a comprehensive check list read verbatim, was mid transition to a modified version using more open questions to help elicit more information from the patient and minimise the potential of missing important medical history.An alert to staff was also issued reminding them of the fundamental principle of our approach to patient safety that when there is any doubt, we must investigate further in order to obtain evidence and not purely take the patients word. We fully understand the medical terminology and the reasons for having to ask specific questions. Patients however cannot be assumed to have a similar level of knowledge and the information they believe can be incomplete or incorrect.
3.	Accompanying nurse from the wards attempted to bring an unchecked oxygen cylinder into the magnet room despite being briefed beforehand in relation to safety around the MRI and specifically the oxygen cylinder. After being stopped by radiographers from taking cylinder any closer to the machine and potentially causing serious harm to both patient and equipment the nurse was unapologetic and did not seem to understand the gravity of the situation despite all the prior warnings.	Lack of awareness and appreciation for the potential severity by the accompanying nurse despite being given advice and warning by MR staff.	A rapid alert was issued to raise awareness of this potentially serious event, in particular raising consideration of safe management of transient items within the MRI controlled access areas. Labelling is used for departmental equipment but is less well considered when items are brought with patients, such as wheel chairs and oxygen cylinders. Suggestion of having labelling available for hanging on equipment was made, or potentially tethering equipment so it can’t be moved. The exclusion of non-MRI staff from waiting within the Controlled Access area was also made.
4.	Following refusal to scan a patient due to the presence of an ICD, the patient’s wife attended the department to say her husband has been scanned a few months ago with it in situ. On review of the patient’s paperwork this had not been documented and should not have occurred as there was no pathway in place locally to manage this and ensure the device was safe etc.	Lack of clarity over roles within the screening process and incomplete documentation. Importance of active discussion with patients around their medical history and style of questioning to ensure reliable recall of history.Importance of clear documentation and record keeping if any responses are corrected or incorrect on the screening form.Reiterate the role and responsibilities of Rad Assistants as MR Environment Authorised Personnel and radiographers as Supervisor MR Authorised Personnel.	A rapid alert was issued as a reminder on staff roles and responsibilities within departments and the MRI Screening process. Similar to the first event 18 months prior, this was around suitable use of support staff in pre-screening and patient prep, but ultimate responsibility resting with the MR Supervising radiographer to check details and speak with the patient before entering the magnet room.
5.	A spate of heating-related issues across the organisation within a 3-month period, in particular one associated with a patient feeling warm whilst wearing a metallic flecked jumped for a scan which should have been removed and potentially resulted in a small skin burn at a potential contact site with the jumper material. Another being a conductive loop where the patient moved their hands together mid scan causing a burn.	Appropriate patient preparation and positioning is needed to ensure the risk of any burn occurring is mitigated. The patient jumper should have been removed and as much as possible patients need to be reminded to not link hands whilst during the examination.	Due to the small collection of similar themed events and complaints a rapid alert was issued to remind staff to be vigilant when prepping and positioning patients. Heating and burns will also provide the content for the next communication programme during MRI Safety Week 2018 so that we can share learning and avoid these preventable events from occurring.

ICD, implantable cardioverter defibrillator.