National Quality Forum highlights key MRI safety issue on list of ‘serious reportable events’
The National Quality forum is adding two key radiology-related safety issues to its list of “serious reportable events.”
NQF, a nonprofit organization working to improve healthcare outcomes, has singled out “patient harm associated with an MRI-related thermal injury” as an important area of concern. Such imaging-related burns often stem from the magnet’s interaction with conductive materials that are in contact with the patient’s skin or improper positioning during an exam, the forum says.
First launched in 2002, the NQF list offers a subset of patient safety events considered serious and largely preventable, often signaling a problem with a healthcare setting’s underlying systems. More than 30 states and hundreds of organizations now use the list for required or voluntary reporting, the forum estimates.
“Serious reportable events—when they occur—provide critical opportunities for learning and improvement,” Elizabeth Mort, MD, MPH, VP and chief medical officer of the Joint Commission, said in a Jan. 26 announcement. “Since the SRE list was last updated in 2011, the landscape of healthcare delivery has evolved in profound ways. New care models and modalities have emerged, and care is now delivered in a wide range of traditional and non-traditional approaches. The newly updated list more accurately reflects today’s modern healthcare environment.”
As part of this update, TJC, another key accreditation entity, also is updating its own list of “sentinel events” to align with the National Quality Forum. Such MRI-related thermal injuries are not listed as individual event by the commission but will now be added to its own sentinel events list beginning Jan. 1, 2027.
In addition, the National Quality Forum is adding a second new radiology-related serious reportable event. It’s highlighting dangers around the delivery of radiotherapy to the wrong patient, wrong body region, an unintended procedure, or greater than 25% above the planned RT dose (regardless of outcome). TJC said it also is updating its list to align with this concern.
The modifications come after NQF launched a process to update its serious reportable events list in 2024 with support from insurer Elevance Health (formerly Anthem) and the Centers for Medicare & Medicaid Services. TJC provided financial support to complete the process and help with updating the list. The two groups said they are seeking to align their recommendations to help with streamlining safety event reporting and eliminating the need to maintain separate safety measurement frameworks.
“This marks a significant step toward simplifying safety event reporting for clinicians, hospitals and health systems worldwide, reducing duplicative reporting tasks and allowing them to focus more on making care safer,” Jonathan B. Perlin, MD, PhD, president and CEO of the Joint Commission,” said in a Jan. 26 announcement.
The two said the new MRI burn safety issue applies to all healthcare settings that perform such exams. This event was previously on the 2011 NQF list (the last update) but experts recommended expanding the intent beyond the introduction of metallic objects. With the change, this now includes all instances, not just those that result in patient harm. Event terminology also was updated from “MRI area” to “MR Zone IV area,” meaning the room where the actual scanner is located.
“Although the level of harm experienced by the individual can vary from no visible or detectable harm to serious harm and death, these events are indicative of potential safety system issues,” the full report from TJC and the NQF says. “Therefore, reviewers should report and analyze all instances of an unapproved, unscreened, or inappropriately approved device, implant, or object that is introduced into an MR Zone IV area to better understand system vulnerabilities, regardless of whether the event was caught before reaching the individual (i.e., near miss), reached the individual and resulted in no harm, or reached the individual and resulted in any level harm.”
Read much more from the two groups here.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.