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Search results for "Root Cause Analysis"
- MRI safety
- Root Cause Analysis
Journal Article > Commentary
Blay E Jr, 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.
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.
Rozovsky FA, Gilk TB, Latino RJ. Mater Manag 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.
Cases & Commentaries
- Web M&M
John Gosbee, MD, MS; Laura Lin Gosbee, MASc; February 2003
An infusion pump being used for routine sedation in a child undergoing a magnetic resonance imaging (MRI) scan flew across the room and hit the MRI magnet, narrowly missing the child.