Pediatric MRI Safety: Frequency, Types, and Severity of Zone IV MRI Safety Events at Five US Children's Hospitals.

Abstract

Data on the frequency and types of MRI safety events in pediatric imaging departments are limited. To assess the frequency, types, and severity of MRI safety events occurring in zone IV across five US pediatric imaging departments. This retrospective study reviewed MRI safety events that occurred in zone IV between 2017 and 2022 at five major US children's hospital systems. The frequency, types (eg, projectile, burn, implant related), and severities of events were recorded using existing institutional MRI safety records. Descriptive statistical analyses were conducted. Over a 6-year period and approximately 540,744 MRI examinations, a total of 146 zone IV MRI safety events were reported across the five institutions. On average, each site experienced 4.9 events per year (range across sites: 1.0-8.5) or 2.5 events per 10,000 MRI examinations (range across sites: 0.9-3.7). Of the 146 events, 44 (30%) involved projectiles, 19 (13%) were burn or thermal injuries, and 14 (10%) were implant related. Ten events (6.8%) were classified as serious safety events. MRI safety protocols were not correctly followed in 88 of 146 events (60%), and 78 of 146 events (53%) directly involved patients. Although uncommon, MRI safety incidents do occur in zone IV of pediatric imaging departments. Although most cause no serious harm, their persistence and potential for catastrophic outcomes highlight the need for continued vigilance and ongoing safety improvements.