'Always-on' magnet often misunderstood
'Always-on' magnet often misunderstood
The Joint Commission's sentinel event database includes five cases that resulted in four deaths and affected four adults and one child, according to Mark R. Chassin, MD, MPP, MPH, president of The Joint Commission.
One case was caused by a projectile, three were cardiac events, and one was a misread MRI scan that resulted in delayed treatment, he says.
A 2005 investigation by Jason Launders, MSc, a medical physicist with the ECRI Institute, a nonprofit health safety group in Plymouth Meeting, MA, found 389 reports of MRI-related events, including nine deaths, in the Food and Drug Administration's Manufacturer and User Facility Device Experience Database reporting database over 10 years.1 There were three related to pacemaker failure, two to insulin pump failure, and the remaining four events related to implant disturbance, a projectile, and asphyxiation from a cryogenic mishap during installation of an MR imaging system.
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Resources can help avoid MRI events When addressing MRI safety, risk managers can depend on the comprehensive guidelines issued by the American College of Radiology (ACR) in 2007.1 That report, along with many other resources for improving MRI safety, are available free of charge by searching the ACR web site (www.acr.org) for "MR safety." To see dramatic examples of how metallic objects can be drawn to an MRI, go to www.youtube.com. In the search box, enter "MRI oxygen bottle" or "Chair gets stuck in MRI machine." The web site, www.simplyphysics.com/ flying_objects.html, has many images of items stuck in MRI machines, including large floor buffers. Many more resources are available at www.MRIsafety.com. Reference 1. Kanal E, Barkovich AJ, Bell C, et al. ACR guidance document for safe MR practices: 2007. Am J Roentgenol 2007; 188:1-27. |
More than 70% of the 389 reports were burns, 10% were projectile-related, another 10% were "other events," including implant disturbance. Four percent were acoustic injuries, 4% were fire-related, and 2% were internal heating-related.
Chassin notes that the projectile injuries can be the most severe, but the most common patient injuries in the MRI suite are burns. The most common objects to undergo significant heating are wires and leads. Other objects associated with burns are pulse oximeter sensors and cables, cardiorespiratory monitor cables, safety pins, metal clamps, drug delivery patches, and tattoos.
"While only one missile-effect case has been reported to The Joint Commission, they are more common than is generally recognized," Chassin says. "Many people, including health care workers, are unaware that the magnets in the MRI scanner are always on and that turning them off is an expensive and potentially dangerous undertaking."
Turning the magnet off, known as quenching, involves the release of dangerous cryogenic gases. Thus, the magnet always is on, which means the machine is dangerous, even when not in use.
Chassin points out that many of the objects pulled into the MRI scanner are cleaning equipment or tools taken into the MRI suite by housekeeping staff or maintenance workers.
Reference
1. Launders J. Hazard report: Patient death illustrates the importance of adhering to safety precautions in magnetic resonance environments. Health Devices 2001; 8:1.
The Joint Commission's sentinel event database includes five cases that resulted in four deaths and affected four adults and one child, according to Mark R. Chassin, MD, MPP, MPH, president of The Joint Commission.Subscribe Now for Access
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