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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.