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Michael Colombini - MRI Case
Descripción
Mapa Mental sobre Michael Colombini - MRI Case, creado por Nikki Davidson el 04/10/2014.
Mapa Mental por
Nikki Davidson
, actualizado hace más de 1 año
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Creado por
Nikki Davidson
hace casi 10 años
48
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Resumen del Recurso
Michael Colombini - MRI Case
People
Michael Colombini, Patient being MRI scanned, 6 yrs old, Sedated, did not get removed for supplementary oxygen
Anesthetist, evidently stressed, unfamiliar with staff on duty, unfamiliar with MRI unit and had no MRI safety training
Hospital Staff
Technician #1 - Received the request for more oxygen as tanks were empty, had no training on Changing tanks, consulted with Technician #2
Technician #2 - Had knowledge on changing tanks, instructed Technician #1 to watch and learn. Both exit control room leaving door open
UIMA employees
Nurse, Heard the urgency for Oxygen, responded by grabbing an oxygen tank from across the hall to MRI suite. Had no official training in MRI safety
Hospital Staff
Unclear roles and responsibilities between UIMA and hospital staff
Workplace
Workplace Factors
No procedure guidelines to follow
Absence of safety manuals onsite
No security to MRI suite
Limited staff - Control room unsupervised
Poor facility design, oxygen room not visible from MRI room
Presence of ferromagnetic canisters on same floor
Two institutes working together
Equipment Design
Safety Zone not clearly marked - no physical barrier to MRI entrance
No warning alarm for depleted oxygen
Switching tanks were time consuming
Back up oxygen not readily available
Failed piped-in oxygen supply
Work environment
Stress from anaesthetist
Powerful electromagnet
Magnetic field "always on"
Poor visibility from MRI room
Increased Noise inside oxygen room
Management
Job design
No Management/supervisor on-site
High change over of staff
Required to do additional jobs in hospital
Job description ambiguity
Information Transfer
No safety signage
Poor communication due to unfamiliarity between the 2 different entities
Unclear organizational communication chart
No microphone to communicate from MRI room to control room
Unclear responsibilities of staff between the Hospital and UIMA
Organisational/system factors
Lack of leadership
Inadequate training on MRI safety for all staff including non-MRI personnel
No institutional or regulatory requirement for MRI training
Previous accident reports not acted upon
No procedure for removal of patient in respiratory distress
No policies written for oxygen equipment
Recursos multimedia adjuntos
mri (image/jpg)
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