MDLinxDiagnostic Disaster: Arizona Woman Receives 50mg Diazepam Instead of Contrast Media in MRI Mishap

Ensuring Patient Safety in Diagnostic Imaging: Lessons from a Medication Error

In a concerning incident at SimonMed Imaging Center in Scottsdale, Arizona, a woman was administered a dangerously high dose of diazepam instead of the intended contrast media during an MRI procedure. This event highlights critical issues surrounding patient safety, procedural adherence, and regulatory oversight in diagnostic imaging practices. As healthcare professionals, it is imperative to glean insights from such incidents to fortify patient safety measures and mitigate risks. This summary distills the essential takeaways from the event and underscores the importance of rigorous safety protocols and continuous education in healthcare settings.

Key Points:

• An Arizona woman was mistakenly given 50 mg of diazepam instead of contrast media during an MRI at SimonMed Imaging Center, significantly exceeding the FDA’s recommended maximum single dose.
• This incident marks the second serious patient safety concern at SimonMed Imaging’s Arizona locations, raising alarms about the consistency of care and safety protocols.
• SimonMed operated without a license from the Arizona Department of Health Services, bypassing the regulatory oversight typically required for such facilities.
• Following the overdose, the patient had to delay important medical treatments and restart anti-seizure medications, illustrating the far-reaching consequences of medical errors.
• Despite acknowledging the mistake, SimonMed denied responsibility for the patient’s subsequent medical issues and controversially billed her for the incomplete MRI procedure.
• In another incident, a patient was injured due to inadequate safety measures regarding metal objects in the MRI room, further questioning the center’s adherence to safety standards.
• SimonMed’s growth and the subsequent reevaluation of its licensure status highlight the evolving regulatory landscape for diagnostic imaging centers and the importance of compliance.
• Experts advocate for a culture of safety within healthcare practices, emphasizing leadership’s role in fostering this environment and the importance of learning from near-miss events.

“Investigating adverse events and errors for the root cause(s) of the patient harm is an excellent, retrospective way to evaluate safety practices. Near-miss events provide an opportunity to determine what went well.“
– Sue Boisvert, BSN, MHSA, Senior Patient Safety Risk Manager for The Doctors Company

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