Prospective review of safety incidents reported in the iMRI OT (Intraoperative magnetic resonance imaging operating theatre)

Abstract

Introduction: The purpose of this study was to determine the types of incidents that occurred in the iMRI OT over a nineteen-month period in our institution. We aim to prevent any future avoidable incidents from happening in this potentially hazardous environment. Methods: This is a single centre prospective non-anonymous observational study conducted from February 2009 to September 2010 on surgeries performed in the iMRI OT. Safety incidents specific to the iMRI OT such as violation of safety protocols and equipment failures were reported as well as any other safety incidents resulting in potential or actual adverse safety outcomes. The outcomes of the incidents were included and the data analysed at the end of the study period. Results: Of 271 cases that were operated in the iMRI OT, 43 incidents were reported by the staff involved in the care of the patient. Of the 43 incidents, 14 incidents (32.6%) were classified as staff/personnel error and were preventable. Incidents resulted in either delayed surgery or cancellation of the surgery. There were no major adverse incidents that led to patient harm. Conclusion: Many of the incidents were preventable and measures have been instituted to prevent the recurrence of such incidents. Staff training, safety protocols and stringent maintenance of equipment are paramount to safe and efficient use of the iMRI operating theatre.