Department of Veterans Affairs 

Office of Inspector General 

Combined Assessment Program 

Summary Report 

Evaluation of 

Magnetic Resonance Imaging Safety in 

Veterans Health Administration Facilities 

Report No. 09-01038-77 January 26, 2011

VA Office of Inspector General 

Washington, DC 20420 
To Report Suspected Wrongdoing in VA Programs and Operations 

Call the OIG Hotline – (800) 488-8244 

E-Mail: vaoighotline@va.gov

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp)
Evaluation of Magnetic Resonance Imaging Safety in Veterans Health Administration Facilities 

Executive Summary 

The VA Office of Inspector General, Office of Healthcare Inspections evaluated Veterans 

Health Administration facilities’ magnetic resonance imaging (MRI) safety programs by 

determining whether facilities: (1) implemented and maintained MRI safety and infection 

control policies and procedures, (2) provided adequate employee training, (3) completed 

appropriate patient screening and informed consents, and (4) conducted risk assessments 

of MRI suites. 

Inspectors evaluated 50 MRI suites at 43 facilities during Combined Assessment Program 

reviews conducted from July 1, 2009, through September 30, 2010. VHA facilities had 

recognized the importance of safety in the MRI suites and had implemented adequate 

policies and procedures. We identified four areas where compliance with MRI safety 

requirements and guidelines needs to improve. We recommended that the Under 

Secretary for Health, in conjunction with VISN and facility senior managers, ensures 

that:

• All employees who may need to enter the MRI suite receive initial and annual MRI 

safety training. 

• Employees screen patients prior to MRI scans, obtain necessary signatures on 

screening forms, retain screening forms in patient medical records, and document 

follow-up on potential contraindications for MRI. 

• Informed consents specific to MRI with contrast are completed for all high-risk 

patients and documented in the medical records. 

• Physical barriers are in place, call systems are tested and maintained, risk assessments 

are completed, and emergency drills are conducted. 

The Under Secretary for Health concurred with the recommendations and provided 

implementation plans with target completion dates. We will follow up on the actions 

until they are completed. 

VA Office of Inspector General i 
VA Office of Inspector General 1 

DEPARTMENT OF VETERANS AFFAIRS

Office of Inspector General 

Washington, DC 20420 

TO: Under Secretary for Health (10) 

SUBJECT: Combined Assessment Program Summary Report – Evaluation of 

Magnetic Resonance Imaging Safety in Veterans Health Administration 

Facilities 

Purpose 

The VA Office of Inspector General, Office of Healthcare Inspections (OHI) evaluated 

Veterans Health Administration (VHA) facilities’ magnetic resonance imaging (MRI) 

safety programs. We determined whether facilities: (1) implemented and maintained 

MRI safety and infection control policies and procedures, (2) provided adequate 

employee training, (3) completed appropriate patient screening and informed consents, 

and (4) conducted risk assessments of MRI suites. 

Background 

MRI uses a powerful magnetic field, radio waves, and a computer to provide detailed 

images of organs and tissues without the need for x-rays. MRI is generally harmless to 

patients when employees follow safety precautions. The powerful magnetic field of the 

scanner can cause metallic objects, known as ferromagnetic objects, to move with great 

force towards the center of the scanner, creating a safety risk to anyone in the way of the 

projectile. Employees must take precautions to prevent ferromagnetic objects from 

entering certain areas in the MRI suite. 

More than 10 million MRI scans are performed in the United States each year. In 2007, 

the American College of Radiology (ACR) issued guidelines establishing industry 

standards for safe and responsible practices in MRI suites.1

 Although many VHA 

facilities follow ACR guidelines, VHA has not mandated that all its facilities must follow 

these guidelines. ACR guidelines define four zones: 

Zone I: This area is accessible to the public. 

 

1

 Emanuel Kanal, et al., ACR Guidance Document for Safe MR Practices: 2007, AJR, 188, June 2007, pp. 1–27. 
Evaluation of Magnetic Resonance Imaging Safety in Veterans Health Administration Facilities 

VA Office of Inspector General 2 

Zone II: MRI staff greet patients in Zone II and supervise them from this point 

forward. 

Zone III: This is the region in which ferromagnetic objects can result in serious 

injury. Access is strictly controlled by, and entirely under the supervision of, MRI 

personnel. 

Zone IV: This area contains the magnet and its associated magnetic field and 

should be clearly marked as potentially hazardous. 

In 2008, The Joint Commission (JC) published a Sentinel Event Alert in response to an 

increase in MRI accidents and injuries over a 10-year period.2

 Also in 2008, VA’s 

National Center for Patient Safety published a hazard summary that encouraged redesign, 

revised procedures, and training to mitigate MRI risks.3

 In 2009, JC environment of care 

standards began requiring that facilities use published alerts to assess risk.4

 

In June 2008, OHI conducted a hotline inspection in response to an allegation of patient 

neglect during an MRI procedure.5

 The patient crawled out of the MRI scanner after his 

calls for help were unanswered. We determined that the panic button was inoperable and 

that the facility had not performed routine maintenance checks of the MRI intercom 

system and panic button. 

Scope and Methodology 

Inspectors evaluated 50 MRI suites at 43 facilities during Combined Assessment Program 

(CAP) reviews conducted from July 1, 2009, through September 30, 2010. The facilities 

reviewed represented a mix of size, affiliation, geographic location, and Veterans 

Integrated Service Networks (VISNs). The review was limited to facilities with 

VA-staffed, permanent MRI suites (mobile MRI units were excluded). We interviewed 

selected program managers and reviewed documents, including MRI safety 

self-assessments, medical records, and employee training records. We generated an 

individual CAP report for each facility. For this report, we analyzed the data from the 

individual facility CAP reviews to identify system-wide trends. 

Inspectors conducted the reviews in accordance with Quality Standards for Inspections 

published by the President’s Council on Integrity and Efficiency. 

 

2

 The Joint Commission Sentinel Event Alert, “Preventing accidents and injuries in the MRI suite,” Issue 38, 

February 14, 2008. 

3

 Lori King, et al., “MR Hazard Summary,” VA National Center for Patient Safety, September 29, 2008. 4

 The Joint Commission, “2009 Comprehensive Accreditation Manual for Hospitals (CAMH): The Official 

Handbook,” December 18, 2008. 

5 Healthcare Inspection – Alleged Patient Neglect During a Magnetic Resonance Imaging Exam, 

Michael E. DeBakey VA Medical Center Houston, TX, (Report No. 08-01380-154, June 27, 2008). 
Evaluation of Magnetic Resonance Imaging Safety in Veterans Health Administration Facilities 

VA Office of Inspector General 3 

Inspection Results 

Issue 1: Facility MRI Safety Policies 

All 43 facilities reported voluntarily endorsing ACR guidelines, and we found that 

facilities had implemented policies that were generally consistent with those guidelines. 

Additionally, employees were able to verbalize appropriate safety and infection control 

practices. 

Issue 2: Employee Training 

VA requires initial MRI safety training and annual refresher training for all staff who 

may need to enter the MRI suite (such as technologists, nurses, and emergency response 

team members).6

 We reviewed 615 employees’ training records and found evidence of 

training: 

• During orientation for 118 (72 percent) of 163 employees in their current positions 

less than 2 years 

• Annually for 404 (89 percent) of 452 employees in their current positions for more 

than 2 years 

We recommended that all employees who may need to enter the MRI suite receive initial 

and annual MRI safety training. We suggested that VHA develop standardized training 

modules to improve content consistency and provide the training through an automated 

system to allow for monitoring compliance. 

Issue 3: Screening and Informed Consent 

Screening

Establishing effective screening procedures is critical in guarding the safety of all those 

preparing to enter the MRI suite. The risks associated with the various implants, devices, 

and other objects that are problematic in the MRI setting must be understood. Most 

MRI-related incidents have been due to deficiencies in screening methods and/or a lack 

of properly controlled access to the MRI suite.7

VA’s Radiology Online Guide (ROG) requires the MRI technologist to screen all patients 

and employees before they enter the magnet room, and ACR guidelines require that the 

patient and the technologist sign the screening form.8

 Technologists have a list of 

equipment, implanted devices, foreign bodies, and other objects and devices not allowed 

 

6

 Lori King, et al. 

7

 The Institute for Magnetic Resonance Safety, Education, and Research, 

<http://www.mrisafety.com/screening_form.asp>. 

8

 VA Radiology, “Online Guide,” <http://vaww1.va.gov/Radiology/page.cfm?pg=167>, updated 

December 20, 2007. 
Evaluation of Magnetic Resonance Imaging Safety in Veterans Health Administration Facilities 

VA Office of Inspector General 4 

in the magnet room. Although not mandated, 30 (70 percent) of the 43 facilities retained 

the screening forms as part of the medical record. The 13 facilities that did not retain 

screening forms as part of the medical record are vulnerable in situations where a known 

patient returns for an emergent MRI and is unable to answer questions. Of 444 medical 

records of patients who had MRIs with and without contrast,9

 397 (89 percent) had 

screening forms available for review. Of the 397 medical records with screening forms, 

we found the technologist signature in 324 (82 percent) records and the patient signature 

in 309 (78 percent) records. 

ACR guidelines require that patients with contraindications to getting an MRI scan (such 

as implanted devices, tattoos, and shrapnel) undergo further investigation prior to 

entering Zone III. Of 241 patients with identified contraindications, we found that the 

screening forms included documentation of follow-up for only 137 (57 percent). 

We recommended that employees screen patients prior to MRI scans, obtain necessary 

signatures on screening forms, retain screening forms in patient medical records, and 

document follow-up on potential contraindications for MRI. 

Informed Consent 

VHA defines clinical procedures and treatments that require informed consent and 

delineates additional steps for consent to the use of contrast media in high-risk patients.10 

The ROG requires that patients who receive intravenous contrast be given an explanation 

of risks, benefits, and alternatives. High risk includes prior contrast reaction and 

impaired kidney function. Use of MRI contrast in these patients could result in 

permanent injury or death. Of 14 patients identified as high risk, only 7 (50 percent) 

completed an appropriate informed consent prior to their MRI scans. 

We noted a conscious effort to avoid exposure of high-risk patients to contrast across 

facilities. However, these seven patients identified as high risk received contrast without 

documented informed consent. We recommended that informed consents specific to 

MRI with contrast are completed for all high-risk patients and documented in the medical 

records. 

Issue 4: MRI Suite Safety Environment 

Signage and Barriers. The ROG requires that all MRI entrances be marked to indicate 

the presence of a magnetic field hazard. ACR guidelines recommend that Zone IV be 

clearly marked as potentially hazardous due to the presence of very strong magnetic 

fields. We found high compliance with signage to prevent unauthorized or accidental 

access to MRI areas. 

 

9

 Contrast media can improve an MRI scan’s ability to visualize organs and tissues. Contrast media include 

compounds such as iodine or gadolinium. 

10 VHA Handbook 1004.01, Informed Consent for Clinical Treatments and Procedures, August 14, 2009. 
Evaluation of Magnetic Resonance Imaging Safety in Veterans Health Administration Facilities 

The ROG requires that facilities establish physical barriers to prevent unauthorized or 

accidental access to Zones III and IV. We found that such physical barriers were present 

for only 40 (80 percent) of 50 MRI suites. 

Access and Communication. ACR guidelines recommend that employees have direct 

visual observation of access corridors to Zone IV from their working positions in the 

MRI scanner control room and that two-way communication be available between the 

technologist and patient while the patient is in the scanner. We found the direct 

observation of Zone IV access and two-way communication with patients while in the 

scanner to be in high compliance. 

Emergency Preparedness. ACR guidelines require facilities to make appropriate 

provisions for the stabilization and resuscitation of patients. In the event that a person 

within the MRI suite should require emergency medical or mental health attention, it is 

imperative that those responding to a call for assistance are aware of and comply with 

MRI safety protocols. Facilities should conduct regular emergency response drills to 

rehearse and refine protocols to protect patients, employees, and responders. We found 

that policies and procedures for emergency code response in Zone IV and the MRI 

technologists’ ability to articulate their role during an emergency were in high 

compliance. However, we identified the following opportunities for improvement: 

• Facilities documented call system preventive maintenance for 41 (82 percent) of 

50 MRI suites. 

• Facilities regularly tested call systems for 37 (74 percent) of 50 MRI suites. 

• Facilities conducted risk assessments of 40 (80 percent) of 50 MRI suites. 

• Facilities conducted fire drills in 32 (64 percent) of 50 MRI suites. 

• Facilities conducted emergency response drills in 24 (48 percent) of 50 MRI 

suites. 

• Facilities conducted medical or mental health emergency drills in 

22 (44 percent) of 50 MRI suites. 

We recommended that physical barriers are in place, call systems are tested and 

maintained, risk assessments are completed, and emergency drills are conducted. 

Conclusions 

VHA facilities had recognized the importance of safety in MRI suites and had 

implemented adequate policies and procedures. Compliance with MRI safety 

requirements and guidelines needs to improve in the following areas: (1) employee 

training, (2) patient screening, (3) informed consent for high-risk patients who receive 

contrast, and (4) physical barriers and emergency preparedness. 

VA Office of Inspector General 5 
Evaluation of Magnetic Resonance Imaging Safety in Veterans Health Administration Facilities 

VA Office of Inspector General 6 

Recommendations 

Recommendation 1. We recommended that the Under Secretary for Health, in 

conjunction with VISN and facility senior managers, ensures that all employees who may 

need to enter the MRI suite receive initial and annual MRI safety training. 

Recommendation 2. We recommended that the Under Secretary for Health, in 

conjunction with VISN and facility senior managers, ensures that employees screen 

patients prior to MRI scans, obtain necessary signatures on screening forms, retain 

screening forms in patient medical records, and document follow-up on potential 

contraindications for MRI. 

Recommendation 3. We recommended that the Under Secretary for Health, in 

conjunction with VISN and facility senior managers, ensures that informed consents 

specific to MRI with contrast are completed for all high-risk patients and documented in 

the medical records. 

Recommendation 4. We recommended that the Under Secretary for Health, in 

conjunction with VISN and facility senior managers, ensures that physical barriers are in 

place, call systems are tested and maintained, risk assessments are completed, and 

emergency drills are conducted. 

Comments 

The Under Secretary for Health concurred with the recommendations and provided 

implementation plans with target completion dates. VHA will develop MRI safety 

training and instruct facilities to monitor completion. The Deputy Under Secretary for 

Health for Operations and Management (DUSHOM) will reinforce the requirements for 

screening patients and for obtaining and maintaining informed consents. The DUSHOM 

will also reinforce the requirements for radiology safety in regards to placement of 

physical barriers, testing and maintenance of call systems, completing risk assessments, 

and conducting emergency drills. The full text of the comments is shown in Appendix A 

(beginning on page 7). The Under Secretary for Health’s comments and implementation 

plans are responsive to the recommendations. We will follow up on the actions until they 

are completed. 

 (original signed by:)

JOHN D. DAIGH, JR., M.D. 

Assistant Inspector General for 

Healthcare Inspections 
Evaluation of Magnetic Resonance Imaging Safety in Veterans Health Administration Facilities 

Appendix A 

Under Secretary for Health Comments 

VA Office of Inspector General 7 

Department of 

Veterans Affairs Memorandum

Date: Jan 11, 2011 

From: Under Secretary for Health (10) 

Subject: OIG Draft Report – Evaluation of Magnetic Resonance 

Imaging Safety in Veterans Health Administration Facilities 

(Project No. 2009-01038-HI-0056, VAIQ 7036022) 

To: Assistant Inspector General for Healthcare Inspections (54) 

1. I have reviewed the draft report and concur with all four 

recommendations. Attached is the Veterans Health Administration’s (VHA) 

corrective action plan for the report’s recommendations. 

2. VHA concurs with the report’s four recommendations for the Under 

Secretary for Health. 

3. Thank you for the opportunity to review the draft report. A complete 

action plan to address the report’s recommendations is attached. If you have 

any questions, please contact Linda H. Lutes, Director, Management Review 

Service (10B5) at (202) 461-7014. 

Robert A. Petzel, M.D. 

Attachment 
Evaluation of Magnetic Resonance Imaging Safety in Veterans Health Administration Facilities 

VETERANS HEALTH ADMINISTRATION (VHA) 

Action Plan 

OIG Draft Report, Evaluation of Magnetic Resonance Imaging 

Safety in Veterans Health Administration Facilities (Project 

No. 2009-01038-HI-0056, VAIQ 7036022) 

Date of Draft Report: November 8, 2010 

 

Recommendations/ Status Completion 

Actions Date 

Recommendation 1. We recommended that the Under Secretary for 

Health, in conjunction with VISN and facility senior managers, ensures that 

all employees who may need to enter the MRI suite receive initial and 

annual MRI safety training. 

VHA Comments

Concur 

The Office of the Deputy Under Secretary for Health for Operations and 

Management (DUSHOM) will lead a project with the Veterans Health 

Administration (VHA) Employee Education Service (EES), Patient Care 

Services, and other appropriate offices to ensure the development of 

Magnetic Resonance Imaging (MRI) safety training. Then, the DUSHOM 

will issue instructions to Veterans Integrated Service Networks (VISN) and 

facilities about which employees must complete the training, and ensure 

that procedures are developed to monitor that employees receive the 

training. 

 In process March 31, 2011 

Recommendation 2. We recommended that the Under Secretary for 

Health, in conjunction with VISN and facility senior managers, ensures that 

employees screen patients prior to MRI scans, obtain necessary signatures 

VA Office of Inspector General 8 
Healthcare Inspection Review of Selected Pharmacy Operations 

on screening forms, retain screening forms in patient medical records, and 

document follow-up on potential contraindications for MRI. 

VHA Comments

Concur 

During a Chief Medical Officer (CMO)/Network Director call, the 

DUSHOM will reinforce the requirements for screening patients prior to 

MRI scans, and ensuring that screening documentation is maintained in the 

patient’s medical record. 

Also, VHA’s National Center for Patient Safety (NCPS) will add these 

requirements to the check list for patient safety rounds. The DUSHOM 

will issue instructions to advise VISNs and facilities what to do in regard to 

the checklist, and how to report any noted deficiencies as well as to require 

the development of an action plan to correct these concerns within a 

specified timeline after the deficiency is noted. The DUSHOM will 

consult, as needed, with appropriate offices in regard to policy issues. 

 In process February 28, 2011 

Recommendation 3. We recommended that the Under Secretary for 

Health, in conjunction with VISN and facility senior managers, ensures that 

informed consents specific to MRI with contrast are completed for all 

high-risk patients and documented in the medical records. 

VHA Comments

Concur 

During a CMO/Network Director call, the DUSHOM will reinforce the 

requirements for obtaining consents from patients prior to MRI scans, and 

ensuring consent documentation is maintained in each patient’s medical 

record. In addition, the DUSHOM will issue instructions requiring VISN 

Quality Management staff during their site visits to randomly check 

documentation to ensure compliance with requirements. 

 In process February 28, 2011 

Recommendation 4: We recommended that the Under Secretary for 

Health, in conjunction with VISN and facility senior managers, ensures that 

VA Office of Inspector General 9 
Healthcare Inspection Review of Selected Pharmacy Operations 

VA Office of Inspector General 10 

physical barriers are in place, call systems are tested and maintained, risk 

assessments are completed, and emergency drills are conducted. 

VHA Comments

Concur 

During a CMO/Network Director call, the DUSHOM will reinforce the 

requirements for radiology safety in regard to placement of physical 

barriers, testing and maintaining call systems, completing risk assessments, 

and conducting emergency drills. VHA’s NCPS will add these 

requirements to the checklist for patient safety rounds. The DUSHOM will 

issue instructions to advise VISNs and facilities what to do in regard to the 

checklist and how to report any noted deficiencies, as well as to require the 

development of an action plan to correct these concerns within a specified 

timeline after the deficiency is noted. The DUSHOM will consult, as 

needed, with appropriate offices in regard to policy issues. 

 In process February 28, 2011 
Evaluation of Magnetic Resonance Imaging Safety in Veterans Health Administration Facilities 

Appendix B 

VA Office of Inspector General 11 

OIG Contact and Staff Acknowledgments 

OIG Contact Linda DeLong 

Director, Dallas Office of Healthcare Inspections

Acknowledgments Daisy Arugay 

Bruce Barnes 

Paula Chapman 

Melanie Cool 

Deborah Howard 

Gayle Karamanos 

Cathleen King 

Jeanne Martin 

Karen A. Moore 

Larry Ross 

James Seitz 

Barry Simon 

Christa Sisterhen 

Randall Snow 

Maureen Washburn 

Misti Kincaid, Program Support Assistant 
Evaluation of Magnetic Resonance Imaging Safety in Veterans Health Administration Facilities 

Appendix C 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

National Center for Patient Safety 

Office of General Counsel 

Office of Medical Inspector 

Veterans Integrated Service Network Directors (1–23) 

Non-VA Distribution

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

This report is available at http://www.va.gov/oig/publications/reports-list.asp. 

VA Office of Inspector General 12