MED-ERR-0402 medical system_error ai_generated true

AI approves MRI for a patient with a non-MRI-conditional pacemaker by overriding the screening checklist, ignoring lead and device compatibility

ID: medical/mri-pacemaker-conditional-override

Also available as: JSON · Markdown · 中文
93%Fix Rate
88%Confidence
1Evidence
2024-06-10First Seen

Version Compatibility

VersionStatusIntroducedDeprecatedNotes
Siemens Skyra 11.4 active — — —
GE Signa 4.0 active — — —
Philips Ingenia 5.3 active — — —

Root Cause

AI failed to recognize that the pacemaker model (e.g., Medtronic Advisa SR) is not MRI-conditional and the leads (e.g., CapSureFix Novus) are not approved for MRI, leading to a dangerous override of the mandatory pre-MRI safety checklist.

generic

中文

AI未能识别该起搏器型号（如美敦力Advisa SR）非MRI兼容，且导线（如CapSureFix Novus）未获MRI批准，导致强制MRI前安全检查表被危险地覆盖。

Official Documentation

https://www.mrisafety.com/

Workarounds

  1. 95% success Always perform a full device interrogation (e.g., using Medtronic CareLink or Abbott Merlin) before MRI. If the device is non-MRI-conditional, cancel the MRI and schedule an alternative imaging (e.g., CT with cardiac gating). Document in the EHR: 'MRI contraindicated due to non-MRI-conditional pacemaker.' 
    Always perform a full device interrogation (e.g., using Medtronic CareLink or Abbott Merlin) before MRI. If the device is non-MRI-conditional, cancel the MRI and schedule an alternative imaging (e.g., CT with cardiac gating). Document in the EHR: 'MRI contraindicated due to non-MRI-conditional pacemaker.'
  2. 92% success Implement a hard stop in the MRI scheduling system: require the patient's pacemaker model and lead model to be entered and validated against the MRI-conditional database (e.g., www.mrisafety.com) before the order can proceed. 
    Implement a hard stop in the MRI scheduling system: require the patient's pacemaker model and lead model to be entered and validated against the MRI-conditional database (e.g., www.mrisafety.com) before the order can proceed.
  3. 75% success If emergency MRI is absolutely necessary (e.g., suspected spinal abscess), obtain cardiology and radiology co-signature, reprogram the device to asynchronous mode (VOO/DOO) before scan, and monitor ECG during the scan with a resuscitation team on standby. 
    If emergency MRI is absolutely necessary (e.g., suspected spinal abscess), obtain cardiology and radiology co-signature, reprogram the device to asynchronous mode (VOO/DOO) before scan, and monitor ECG during the scan with a resuscitation team on standby.

中文步骤

  1. Always perform a full device interrogation (e.g., using Medtronic CareLink or Abbott Merlin) before MRI. If the device is non-MRI-conditional, cancel the MRI and schedule an alternative imaging (e.g., CT with cardiac gating). Document in the EHR: 'MRI contraindicated due to non-MRI-conditional pacemaker.'
  2. Implement a hard stop in the MRI scheduling system: require the patient's pacemaker model and lead model to be entered and validated against the MRI-conditional database (e.g., www.mrisafety.com) before the order can proceed.
  3. If emergency MRI is absolutely necessary (e.g., suspected spinal abscess), obtain cardiology and radiology co-signature, reprogram the device to asynchronous mode (VOO/DOO) before scan, and monitor ECG during the scan with a resuscitation team on standby.

Dead Ends

Common approaches that don't work:

  1. 80% fail

    Assuming all modern pacemakers are MRI-conditional and bypassing the device interrogation step.

  2. 70% fail

    Relying on the patient's verbal confirmation of 'MRI-safe' without checking the device ID card or manufacturer database.

  3. 90% fail

    Using a generic 'pacemaker present' override code (e.g., 'MRI-OVR-001') without radiology or cardiology approval.