When New Equipment Causes Unexpected Harm: What the MRI Thermal Injury Case Teaches Veterinary Hospitals

A nine-month investigation into skin burns at an academic veterinary hospital reveals how multiple small failures can align to cause patient harm and what systematic approaches can prevent it.

Here's a scenario every veterinary hospital hopes never happens: you upgrade equipment designed to improve patient care, and instead, patients start getting hurt.

That's what happened at the University of Florida Veterinary Hospitals after a 2024 MRI upgrade. Within weeks, dogs undergoing MRI with electrocardiographic monitoring began experiencing thermal skin injuries at the electrode sites. Ten dogs total experienced burns—some mild, some severe second-degree burns confirmed by biopsy.

The investigation that followed took nine months. It involved system engineers, physicists, consultants, root cause analysis, fishbone diagrams, and the 5 Whys methodology. It included biopsies, cadaver testing, equipment replacement, and profound uncertainty about what was actually happening.

The case study, published recently in the American Journal of Veterinary Research, reveals something hospitals need to understand: patient safety isn't just about individual mistakes. It's about systems, culture, and how multiple small failures can align to cause harm.

The Timeline: How Harm Unfolded

The first dog (index case) experienced redness and thermal injury at two electrode sites during a brain MRI scan within two weeks of the equipment upgrade. The team responded quickly: they implemented a post-MRI skin assessment checklist and increased attention to patient preparation. They thought they'd caught it early.

They were wrong. Within a week, five more dogs developed thermal skin lesions of varying severity. Some resolved in hours. Others developed severe erythema, indentation, and crusting. The team faced a choice: keep going, or pause the procedure and investigate.

They paused. They launched a comprehensive investigation.

The Investigation: Why It Was So Hard

Here's what makes this case so instructive: the investigators did everything right, and it still took nine months to solve. The MRI system passed all technical evaluations. The equipment specifications were within FDA-approved limits. The specific absorption rate (SAR)—the measure of radiofrequency energy absorbed by tissue—was within normal ranges. All components tested as normal. Patient preparation was reviewed and criticized by external trainers. Electrode quality was evaluated. The cables were replaced. A new transmitter was installed.

And dogs kept getting burned.

The investigators used the 5 Whys methodology, root cause analysis, fishbone diagrams, and PDSA cycles (Plan-Do-Study-Act). They evaluated human factors, patient factors, procedural factors, environmental factors, and equipment factors. They tested electrodes on a cadaver during an MRI. Nothing obviously explained what was happening.

What finally broke the case was a combination of two things: biopsies that confirmed the burns were indeed thermal injuries (not pressure injuries, not contact dermatitis), and a willingness to question whether the "upper end of the acceptable range" was actually acceptable for this particular application.

The Solution: And Why It Was Counterintuitive

The upgraded MRI system was supposed to be safer. It incorporated new technology designed to reduce radiofrequency exposure and mitigate thermal injury risk. The pulse energy method for measuring SAR is more precise than the older method. The dual-transmit radiofrequency technology improves field homogeneity and reduces localized hotspots. These are safety features.

But the hospital's resolution came not from accepting these features or investigating more deeply into the equipment itself. It came from reducing radiofrequency power by 200 watts—bringing it from the upper end of the acceptable range into the middle of that range. After that change, no further thermal injuries occurred through December 2025.

The researchers theorize that the improved efficiency of the upgraded system allowed for inductive heating that concentrated radiofrequency energy at the electrode sites, leaving little margin for technical deviations in patient preparation or other unidentified risk factors when operating at the higher power setting.

In other words: the system was so efficient that it was too efficient. It could concentrate energy in ways the older system couldn't. Operating at maximum safe limits wasn't safe in this specific context.

The Swiss Cheese Model: Understanding System Failures

To understand how this happened at a well-managed academic hospital with experienced staff, the researchers used James Reason's Swiss Cheese Model—a framework for understanding how multiple small failures can align to create patient harm.

Imagine multiple sheets of Swiss cheese stacked on top of each other. Each sheet has holes, but usually the holes don't line up. It's only when multiple holes align that light passes through—that harm reaches the patient.

In this case, the "holes" might be: new equipment with unexpected energy concentration behavior, routine monitoring electrodes designed for conventional MRI settings, staff who had never seen this problem before and therefore didn't suspect it, a system that technically complied with safety standards, and acceptance of maximum safe power levels.

No single factor caused the harm. It took all of them aligned together.

What This Means for Your Hospital

If you work at a veterinary hospital, several lessons from this case apply directly to your practice:

Equipment upgrades carry risk. When you upgrade equipment, especially high-tech diagnostic equipment, don't assume the new system will behave exactly like the old one. Monitor patients carefully after upgrades. Establish baseline assessments. Compare outcomes before and after.

Technical compliance isn't always sufficient. A system that passes all technical evaluations and complies with regulatory standards can still cause harm in a specific clinical context. This doesn't mean regulations are wrong. It means regulatory compliance is a floor, not a ceiling.

Just culture matters. This investigation only succeeded because the hospital had a patient safety reporting system in place since 2017. Because employees felt empowered to report events. Because the leadership focused on solving the problem rather than blaming individuals. In hospitals without that culture, the burns might have been rationalized away or blamed on staff error.

Get diagnostic confirmation. Initial assumptions about what's happening—pressure injury versus thermal injury—matter. Biopsy confirmation, though it took time and resources, ultimately redirected the investigation toward the actual cause. Don't skip diagnostics to save time.

Multiple small failures align. The Swiss Cheese Model isn't just theory. This case proves it. Fix the obvious problem (replace cables and transmitter), and you might not solve the underlying issue. You need to look at the system, at context, at the interaction between equipment and procedure and personnel.

The Broader Patient Safety Lesson

This case study is worth reading in full—not because every hospital will face MRI thermal injuries, but because it demonstrates how to respond when unexpected patient harm occurs. The University of Florida team used structured methodology. They investigated systematically. They consulted experts. They questioned their assumptions. They didn't stop at the first plausible explanation. They prioritized resolution over convenience.

That's patient safety. That's hospital excellence. And it takes time.

The fact that they published this—not hiding the problem, but making it public so other hospitals could learn—is itself a lesson in professional responsibility and a just culture.