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Publication Type: Risk Alert
Single or Multiple Incident: Multiple
Date: 4/1/2020 12:00:00 AM
Country: Hong Kong
This alert describes two patient safety incidents where metal objects were placed into the MRI device with the patient. A sandbag with a metallic element was wrapped by bed linen and put under the patient’s head and neck for support. This was not noticed during visual inspection for any metallic objects, and NO alarm signal was generated by the handheld metal detector. In the scan room, the patient was secured and positioned. When the table was moving into the gantry, the sandbag was attracted to the facade of the scanner. In the second incident, a patient with a disposable warm blanket required a spine MRI examination. No abnormality was detected by the handheld metal detector. When the patient was transferred into the scanner, the blanket was attracted to the magnet of the MRI machine. Recommendations to prevent similar incidents are provided.

Additional Details

Device:
magnetic resonance imaging (MRI) scanner, sandbag, disposable warm blanket, metal insert, handheld metal detector

Environment / Equipment
  1. Adhere to any restrictions provided by suppliers regarding the use of MR-safe equipment and devices in the MRI environment.
Rules / Policies / Procedures
  1. Screen patients for implants and appliances that may be hazardous.
  2. Use a standardised checklist for safe working in MRI environment.
  3. If an object flies into the magnet, it should not be reached for until the MRI machine has stopped moving.
  4. Follow MRI safety-related guidelines.

Magnetic Resonance Imaging (MRI) Safety