Description of Event or Problem · 1
THIS IS ONE OF TWO RECENT EVENTS WHERE RIGHT AND LEFT (LATERALITY) WERE REVERSED ON THE CORONAL MRI IMAGES PERFORMED ON A GE. THE NEUROSURGEON HAS BEEN IN CONTACT WITH RADIOLOGY/IMAGING LEADERSHIP ABOUT THESE LATERALITY ISSUES. THE CAUSE IS EVIDENTLY RELATED TO TECHNOLOGIST'S ERROR IN INPUTTING DATA AFTER A RECENT GE SOFTWARE UPGRADE, BUT THE SOFTWARE ALLOWS THIS TO HAPPEN WITH PATIENT ORIENTATION CHANGES UNKNOWN TO THE TECHNOLOGIST PERFORMING THE STUDY. THIS TYPE OF ERROR OBVIOUSLY HAS SIGNIFICANT RISK OF WRONG SIDED SURGERY IF THE ERROR IS NOT CAUGHT. EVEN WHEN THE ERROR IS CAUGHT, THERE REMAINS SIGNIFICANT EXPOSURE FOR A PATIENT ERROR LATER BECAUSE THESE IMAGES ARE INCLUDED IN THE PATIENT'S ELECTRONIC MEDICAL RECORD AND COULD BE VIEWED BY A SURGEON IN THE FUTURE, WHO IS UNAWARE THAT THIS LATERALITY ISSUE IMPACTED THE VIEWS THAT SHE/HE IS SEEING. MANUFACTURER RESPONSE FOR GE 26 & 28.O PLATFORM, (BRAND NOT PROVIDED) (PER SITE REPORTER): GE IS AWARE. OUR MR IMAGING LEADERS HAVE BEEN IN COMMUNICATION WITH OUR PHYSICIAN AND TECHNOLOGIST STAFF IN REGARD TO THIS ISSUE ACROSS ALL OUR CAMPUSES AND HAVE ASKED THAT A GADOLINIUM MARKER BE PLACED ON THE LEFT TEMPLE FOR ALL BRAIN MRI CASES. OUR MR IMAGING LEADERS ARE CURRENTLY REVIEWING MARKER PLACEMENT WITH STAFF AND WILL BE AUDITING ALL BRAIN MRI CASES TO ENSURE COMPLIANCE. IN ADDITION, WE HAVE BEEN IN COMMUNICATION WITH GE ON A SOFTWARE PATCH. THE CURRENT TIMELINE ¿PER GE¿ FOR COMPLETION IS DECEMBER 2021. THIS TIMELINE IS UNACCEPTABLE TO THE MRI LEADERSHIP TEAM (THIS IS A HUGE SAFETY CONCERN). DISCUSSIONS AS IT RELATES TO THIS ISSUE ARE ONGOING AS WE LOOK FOR A PERMANENT SOLUTION FROM GE.