Faulty MRI Positioning Leads to Patient Death

Case Summary

This case involves a 74-year-old man with a history of congestive heart failure (CHF), obstructive sleep apnea (OSA), chronic kidney disease, stage III bilateral (BL) phrenic nerve palsy, and chronic hypoxemic with hypercarbic respiratory failure. An MRI of the lower extremity was ordered during hospitalization for sepsis to rule out osteomyelitis.

The treating internist administered 2 mg IV Ativan as a sedative to reduce excessive motion artifacts caused by patient discomfort.

Radiology was not informed by the ordering physician that the patient should not lay flat during the MRI. This was documented in the patient’s medical record as necessary for this patient due to respiratory comorbidities. The patient went into respiratory arrest during the study. In this case, no intervention was attempted because the patient was DNR/DNI.

Case Theory

Magnetic resonance imaging, or MRI, is a popular imaging test for diagnosing conditions not visible on x-rays. There are more than 30 million MRI scans performed annually in the United States. The field of MRI safety has grown significantly over the past twenty years. MRI environments are undergoing widespread efforts to standardize safety protocols, including mandated institutional safety procedures. Poor outcomes are often caused by a lack of knowledge about MRI safety protocols or incomplete medical information.

While MRI-related incident reports are relatively infrequent, inpatients experience them at significantly higher rates, and they can cause various levels of harm to patients. The most frequent incidents related to safety are faulty diagnostic test orders, adverse drug reactions, and medication/IV safety. The number of adverse events associated with hospital admissions is estimated at 10%, and approximately 40%–50% of these events are preventable. Human fallibility and the sheer volume of MRI exams contribute to an increase in errors.

In healthcare, incident reporting systems facilitate the identification and correction of errors. Any healthcare quality and safety framework, including radiology, must incorporate incident reporting of accurate medical information to technicians. Negligence in the failure to disclose critical information is malpractice.

In this case, the administration of 2 mg IV Ativan and failure to communicate that the patient should not be supinely positioned were breaches of standard medical care that resulted in the death of the patient.

Expert Witness Specialities

Internal Medicine

An Internal Medicine expert can opine on the standard of care in relaying patient positioning needs.

Radiologist

An expert in radiology can opine on the importance of relaying positioning information to the MRI technician and speak to the breach of the standard of care in this case.

Hospitalist

An expert hospitalist is able to opine on hospital standard of care and failures to disclose vital information.

Questions for Expert Witnesses

• How often are inpatient imaging studies ordered for patients with significant comorbidities that adversely affect respiration, such as OSA, CHF, chronic respiratory failure, and BL phrenic nerve palsy?
• What measures are required to safely sedate similar patients for imaging?
• What is the standard of care for communicating important positioning requirements to radiology personnel for imaging studies?

Expert Witness Involvement

Here is what the internal medicine expert in this case had to say:

Expert Witness Response E-104363

I've been working in the internal medicine field for over 20 years. I have experience working in both private practice and academically-affiliated institutions. I order inpatient imaging studies for patients with various comorbidities affecting respiration on a daily basis. To safely sedate patients for imaging, the doctor needs to make sure to monitor the patient's oxygen and heart rate. Important positioning requirements to radiology personnel for imaging studies are usually written and then communicated via phone.