Patient safety investigative methods identify contributors to canine magnetic resonance imaging dermatologic thermal injuries in an academic hospital

Objective: To describe MRI-associated ECG electrode site thermal burns in dogs and the patient safety investigation that identified a reduction of radiofrequency energy output as a modifiable factor associated with their resolution. Animals: 10 client-owned dogs undergoing MRI that experienced skin lesions at the ECG electrode site from April through December 2024. Clinical Presentation: The reason for MRI was brain imaging in 5 dogs, spine imaging in 4 dogs, and both brain and spine imaging in 1 dog. Median weight was 14.7 kg (range, 3.1 to 31.5). Median age was 9 years (range, 1 to 13). Results: After an MRI upgrade, 10 dogs experienced skin lesions consistent with thermal injury at the ECG electrode site. Thermal injury was mild (7) and moderate to severe (3). Two dogs underwent skin biopsy, which confirmed second-degree burns. A comprehensive, systematic, iterative approach to investigate these patient harm events was undertaken, involving multiple investigations and procedural changes. Resolution came after MRI radiofrequency energy output was reduced despite being measured in the acceptable range. Clinical Relevance: The approach used to investigate MRI-associated thermal burns in this study highlights the importance of identifying root causes to improve system safety and ultimately prevent future harm. Histologic confirmation of thermal injury has not previously been reported in dogs and was important because it refocused the investigation on MRI output as a potential cause.