Changing the way you learn

Michael Colombini - MRI Case

People
1. Michael Colombini, Patient being MRI scanned, 6 yrs old, Sedated, did not get removed for supplementary oxygen
2. Anesthetist, evidently stressed, unfamiliar with staff on duty, unfamiliar with MRI unit and had no MRI safety training
  1. Hospital Staff
3. Technician #1 - Received the request for more oxygen as tanks were empty, had no training on Changing tanks, consulted with Technician #2
4. Technician #2 - Had knowledge on changing tanks, instructed Technician #1 to watch and learn. Both exit control room leaving door open
  1. UIMA employees
5. 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
  1. Hospital Staff
6. Unclear roles and responsibilities between UIMA and hospital staff
Workplace
1. Workplace Factors
  1. No procedure guidelines to follow
  2. Absence of safety manuals onsite
  3. No security to MRI suite
  4. Limited staff - Control room unsupervised
  5. Poor facility design, oxygen room not visible from MRI room
  6. Presence of ferromagnetic canisters on same floor
  7. Two institutes working together
2. Equipment Design
  1. Safety Zone not clearly marked - no physical barrier to MRI entrance
  2. No warning alarm for depleted oxygen
  3. Switching tanks were time consuming
  4. Back up oxygen not readily available
  5. Failed piped-in oxygen supply
3. Work environment
  1. Stress from anaesthetist
  2. Powerful electromagnet
  3. Magnetic field "always on"
  4. Poor visibility from MRI room
  5. Increased Noise inside oxygen room
Management
1. Job design
  1. No Management/supervisor on-site
  2. High change over of staff
  3. Required to do additional jobs in hospital
  4. Job description ambiguity
2. Information Transfer
  1. No safety signage
  2. Poor communication due to unfamiliarity between the 2 different entities
  3. Unclear organizational communication chart
  4. No microphone to communicate from MRI room to control room
  5. Unclear responsibilities of staff between the Hospital and UIMA
3. Organisational/system factors
  1. Lack of leadership
  2. Inadequate training on MRI safety for all staff including non-MRI personnel
  3. No institutional or regulatory requirement for MRI training
  4. Previous accident reports not acted upon
  5. No procedure for removal of patient in respiratory distress
  6. No policies written for oxygen equipment

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Michael Colombini - MRI Case

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	Created by Nikki Davidson almost 10 years ago