SSQ17-02

Identification of Quality Improvement Areas in Pediatric MRI from Analysis of Patient Safety Reports

Thursday, Dec. 1 10:40AM - 10:50AM Room: S102C



Awards
Student Travel Stipend Award

Participants
Camilo Jaimes Cobos, MD, Boston, MA (Presenter) Nothing to Disclose
Diana Murcia, MD, Boston, MA (Abstract Co-Author) Nothing to Disclose
Karen Miguel, RN, MPH, Boston, MA (Abstract Co-Author) Nothing to Disclose
Cathryn Defuria, RN, Boston, MA (Abstract Co-Author) Nothing to Disclose
Pallavi Sagar, MBBS, Boston, MA (Abstract Co-Author) Nothing to Disclose
Michael S. Gee, MD, PhD, Jamaica Plain, MA (Abstract Co-Author) Nothing to Disclose

PURPOSE

To estimate the rate of safety reports in pediatric MRI and determine risk factors associated with safety report frequency.

METHOD AND MATERIALS

In a retrospective HIPAA-compliant, IRB-approved study, the RIS was queried to identify MRI studies performed in pediatric patients (0-18 yrs) from 2010-2015 and then cross-matched with the institutional safety incident reporting system. Safety report (SR) severity was graded on a 5-point scale: did not reach/affect the patient, reached but did not affect the patient, caused minor harm (IV infiltration, skin injury), caused major harm (anaphylaxis, code), or death.  Patient age, location, and the use of sedation/GA were recorded. Chi-square test was used to evaluate significance of differences between groups. 

RESULTS

A total of 89 SR were identified from a total of 16749 pediatric MRI studies, yielding a prevalence of 0.53%. In 15 reports (17%) the event did not reach and did not harm the patient, 39 (44%) reached the patient but caused no harm, 32 (36%) caused mild harm, and 3 (3%) caused major harm. There were no deaths. The two most common causes for SR were service coordination (n=32; 36%) and adverse drug reactions (n=17; 19% ). 3482 (20.7%) MRIs involved sedation/GA. There was  a significantly increased SR rate in MRIs that used sedation/GA (0.8%) relative to awake MRI (0.46%), with an odds ratio (OR) of 1.75 (P<0.05). SR rate also varied significantly by location (p<0.05), with a rate of 1.2% for inpatients, 0.6% for E.R. patients, and 0.4% for outpatients.  Increased SR rates were seen in the younger age categories, with newborns (1.1%), infants (1.1%), and young children ( 0.9%) associated with SR rates significantly higher than those in older children (P < 0.05) . The odds ratio of younger children (<6 yrs) having a SR relative to older children (>6yr) was 2.2.

CONCLUSION

The prevalence of safety reports in MRI performed in children is increased relative to previously published data on adults. The majority of events caused no harm or only minor harm. The most common causes of SRs were service coordination and adverse drug reaction. Children below the age of 6 yrs, inpatients, and use of sedation/GA are all factors associated with higher SR rates and should be the focus of quality improvement strategies. 

CLINICAL RELEVANCE/APPLICATION

Data on safety reports in pediatric MRI is sparse. Knowledge of safety profile of pediatric MRI can be used to guide evidence-based recommendations.