by Darla Stuart - Aurora, CO
There are NO MRI patient safety standards ... patients deserve better!
Please sign our White House petition to make a change: wh.gov/ztj
The United States (US) Food and Drug Administration (FDA) reported in 2011 that MRI accidents in the US have risen over 500+% from 2000 to 2009. The overwhelming majority of reported injuries fell into one of three categories: burns, projectiles and hearing damage. However, these injuries are not accidents: they are directly related to the failure to assure proper safety standards.
In 2008, our, then, fifteen year old daughter walked into a Children’s Hospital in Colorado to have an MRI. She had been living with scoliosis and needed have the dreaded spinal fusion surgery. More than a half-an-hour behind schedule the technician rushed her through the screening as it was late, the last appointment of the day. Precautions like a two way audio system, safe and inspected equipment and a panic button, which were advertised on the Hospital’s website, were non-existent. Thirty minutes later our daughter crawled out of the MRI machine of her own accord: alone, traumatized and injured.
The video goggles that were offered by a Children’s Hospital in Colorado to help her relax during the procedure were faulty. They had been recently returned to service after being repaired by the Hospital’s own Biomedical Department. A plastic casing, part of the video goggle manufacturer’s original design, meant to cover the metallic webbing of the video goggles had been removed and not replaced during the most recent repair. So, at the moment the MRI started a piece of tungsten metal from the video goggles, acting like a magnetized projectile, soldered to our daughter’s eyelid and burned like an ember during three MRI cycles while she laid in there asking, begging, crying for help: help that never came. The attending technician had turned the patient microphone down because the noise of the MRI was disturbing to other radiology staff.
The a Children’s Hospital in Colorado knew within hours that: the goggles had been improperly repaired by their biomedical department; the microphone had been turned down too low by their staff to hear our daughter’s cries; and the panic button, meant to be an additional safety procedure, was not installed. They knew that her injuries were not a result of an accident, but caused by their systemic failure to assure proper safety standards. Sadly, though, they blamed her for their negligence and treated her with cold indifference.
Our daughter’s injury was much deeper than the multiple lacerations on her eyelid, her innocence was lost and her trust of others was shattered. As the wounds on her eyelid healed and scarred, the wounds in her soul festered. She found herself waiting for the next bad thing to happen, preparing herself for what she would do if she had to save herself, living in fear every day. Ultimately, she felt like the fear she lived with every day was too much and she considered suicide. She has received therapy to help overcome her post traumatic stress reaction, and will likely never be free of the heightened anxiety she experiences as a direct result of this life changing incident.
On May 16, 2012, four plus years after our daughter’s injury a jury in Adams County found a Children’s Hospital in Colorado guilty of medical negligence. That verdict not only publicly confirmed to our daughter that she was indeed a victim of their negligence, but it gave us the freedom to speak about that negligence as substantiated through a public record. At trial it was admitted into evidence via a Children’s Hospital in Colorado staff member’s testimony that the panic button that was to have been mandatorily placed into service was often removed because children used it too frequently. Further it was stated that the safety manual, which was allegedly written after our daughter’s incident to retrain staff on MRI safety, hadn’t been instituted and staff weren’t even aware that it existed.
Our daughter’s injury could and should have been avoided. Her injuries were not caused by an accident or a device malfunction; they were directly caused by the failure to assure and implement common and highly recommended safety standards. Safety standards that remain, as of today, inconsistently applied to children who use A Children’s Hospital in Colorado MRI equipment.
Industry leaders agree that there should be safety standards that provide regulated oversight for MRI safety. Colorado does not regulate or inspect MRI equipment or associated items used in MRI’s. Additionally, Colorado doesn’t require that MRI technicians be licensed. Essentially, each facility that offers a MRI service is allowed to independently regulate how they oversee their equipment and determine staff credentials. Tragically in our experience that independent oversight was absent.
Statistics indicate that with a 500+% increase in reported accidents it is highly probable that another child will be a victim of this type of negligence. We can’t turn back time and change what happened to our daughter. Although, we can insist regulations are created and government oversight provided. We can warn parents to do what A Children’s Hospital in Colorado refused to do:
- require staff perform a parent observed inspection of the MRI and associated equipment;
- require staff perform a parent observed test of the two way audio system with their child;
- require staff perform a parent observed test of panic button with their child.
We can speak publicly about our experience, and invite others in join us in demanding that no other child be a victim of this type of avoidable negligence.
