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This WebM&M highlights two cases of patient safety events that occurred due to medication dosing related to diagnostic imaging. The commentary highlights the challenges of administering sedation for diagnostic imaging, the use of risk stratification to understand patient risk for oversedation, and strategies for appropriate monitoring and communication.

Sajid IM, Parkunan A, Frost K. BMJ Open Qual. 2021;10:e001287.
Inappropriate use or overuse of clinical tests such as MRIs can be harmful to patients. This cohort study, including 107 general practitioners across 29 practices, found that only 4.9% of musculoskeletal MRIs were clearly indicated and only 16.7% of results appeared to be correctly interpreted by clinicians, suggesting the potential for significant misdiagnosis and overdiagnosis.

FDA Safety Communication. MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; December 7, 2020.

Magnetic resonance imaging (MRI) requires patient preparation steps to protect against inadvertent harm. This announcement cautions patients and providers to assess masks being worn to protect against COVID-19 transmission for metal components that can result in patient burns during the exam. Recommendations for safety include enhanced screening to ensure masks are safe for the exam environment.

ACR Committee on MR Safety, Greenberg TD, Hoff MN, Gilk TB, et al. J Magn Reson Imaging. 2020;51(2):331-338. 

The reliable adoption of safe practices in clinical and research imaging will reduce risks to diagnostic radiology patients. This guideline builds on existing recommendations as a response to the changing needs of magnetic resonance practitioners and their patients. Strategies to ensure clinical teams stay updated on safety issues in this environment include reviewing and updating guidelines as well as requiring magnetic resonance directors to undergo annual patient safety training.
Goolsarran N, Martinez J, Garcia C. BMJ Open Qual. 2019;8:e000593.
Near misses can uncover process weaknesses and motivate improvement to prevent similar incidents. This commentary outlines how one hospital used Plan–Do–Study–Act cycles to improve their MRI screening process, including developing and implementing a safety checklist in the electronic medical record and building in a hard stop to prompt checking for contraindications.
After presenting with new left-sided weakness and hypertensive urgency, a woman was admitted to the stroke unit, and the consulting neurologist ordered an urgent MRI of the brain. Although the patient required pushes of intravenous hypertensive medication to control her blood pressure (BP), she was taken to radiology where the nurse checked her BP one more time before leaving her in the MRI machine with the BP cuff still on. Within a few seconds of starting the scan, the patient's arm with the BP cuff was sucked into the MRI scanner, making a loud noise.
An ICU patient with head and spine trauma was sent for an MRI. Due his critical condition, hospital policy required a physician and nurse to accompany the patient to the MRI scanner. The ICU attending assigned a new intern, who felt unprepared to handle any crises that might arise, to transport the patient along with the nurse. While in a holding area awaiting the MRI, the patient's heart rate fell below 20 beats per minute, and the experienced ICU nurse administered atropine to recover his heart rate and blood pressure.

Azar FM, ed. Orthop Clin North Am. 2018;49(4):A1-A8,389-552.

Quality and value have intersecting influence on the safety of health care. Articles in this special issue explore key principles of safe orthopedic care for both adult and pediatric patients. Topics covered include leadership's role in implementing sustainable improvement, postsurgery patient education as a safety tactic, and the impact of surgical volume on safe, high-quality care.
Blay E, Barnard C, Bilimoria KY. JAMA. 2018;319:495-496.
This commentary describes a case involving a patient with obstructive sleep apnea who received multiple sedating medications and subsequently had a cardiac arrest while undergoing MRI. The authors explore root causes and provide suggestions for improving the safety of care for patients with obstructive sleep apnea.
Abujudeh H, Kaewlai R, Shaqdan K, et al. American Journal of Roentgenology. 2017;208.
This review summarizes key principles of high quality care and how they can be applied to augment radiology practice. Recommended safety improvement strategies included plan-do-study-act cycles, change management, and balanced scorecards.
Mansouri M, Aran S, Harvey HB, et al. J Magn Reson Imaging. 2016;43:998-1007.
This analysis of incident reports related to magnetic resonance imaging found that, similar to other settings, incident reports are infrequent, and most do not result in patient harm. Common reasons for reports were associated with test orders, adverse drug reactions, and safety of intravenous medication administration. Given known under-reporting in voluntary reporting systems, future work should incorporate other safety hazard detection methods.
Gilk T, Kanal E. J Magn Reson Imaging. 2015;42:566-71.
Although rare, adverse events still occur during magnetic resonance imaging (MRI). These incidents can be prevented through increased attention to the design of the environment in which scanners are used. This commentary describes the benefits to engaging frontline personnel in site planning to enhance MRI safety.
Gilk T, Latino RJ. Patient Saf Qual Healthc. November/December 2011;8:22-23,26-29.
Describing a case of accidental patient death in an MRI suite, this article reviews a root cause analysis of the event and notes that no regulatory efforts have been implemented to improve MRI safety in the 10 years following the incident.
Sentinel Event Alert. 2008;38:1-3.
This alert provides risk reduction strategies and recommendations to minimize opportunities for failures associated with the use of magnetic resonance imaging (MRI). Note: This alert has been retired effective August 2016. Please refer to the information link below for further details.
International Society for Magnetic Resonance in Medicine.
MRI Safety Week is held annually in July. This observance  supports the sharing of information and resources to support magnetic resonance imaging safety.
Rozovsky FA, Gilk TB, Latina RJ. Materials management in health care. 2006;15:18-23.
This article discusses risk management in magnetic resonance imaging facilities and the use of root cause analysis to inform risk management methodologies.