Hard Stops in the Computerized Physician Order Entry Process to Improve MR Patient Safety

Purpose: To highlight the use of a hard stop system in the MR ordering process.

Educational Objectives:
-Learn how hard stops can reduce unwanted events.
-Show the steps needed to employ hard stops into the computerized physician order entry (CPOE).
-Overcome adverse effects of instituting hard stops, such as workflow disruptions.

Methods/Materials: In conjunction with IT and our Cardiology department, we have implemented a hard stop system into the CPOE for MR. We focus on cardiac implantable electronic devices (CIEDs). A hard stop is an inflexible decision to halt an order, proceeding only with external override. Prior to its use, we employed ACR safety guidelines for patients with CIEDs, denying access to zone III of the MR suite unless signed off by a radiologist. A few close calls still occurred where patients arrived only to be halted by technicians who noted unreported pacemakers. With hard stops, the CPOE automatically prompts the ordering provider to contact the cardiologist when an MR-Unsafe or Conditional CIED is reported. The cardiologist assesses the device model number and documents placement in safe mode and at what time the device will return to original settings. This is electronically transferred to the MRI questionnaire for the technicians and the radiologists can give their approval. A clinician attestation must then be signed to proceed.

Results: Hard stops streamline the ordering process, and improve accuracy and patient safety. Note that orders that are hard stopped may impede the workflow. Interdepartmental communication and collaboration is essential. Keep in mind that the MR is always on. Hard stops are an important safety measure, however the technologists are still gatekeepers. They reassess and screen all patients prior to having them enter the MR exam room.

Conclusions: Implementation of a hard stop system has increased MR ordering confidence for CIED patients while significantly decreasing adverse events. We are expanding hard stops to include patients with other types of ferrous objects and implants.