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Publication Type: Patient Safety Bulletin
Single or Multiple Incident: Single
Date: 5/1/2007 12:00:00 AM
"A 10-lb sandbag was placed in a pillow case under a patient to support an arterial line. The patient was then taken for an MRI. After changing all the equipment to MRI compatible, the patient was taken into the room, at which time the sand bag flew from under the patient into the MRI core. The bag split open after being removed from the MRI, revealing small black grains similar to graphite. There was no harm to the patient. Contributing factors included the sandbag being hidden by the pillow case in the patient's bed linen, and wanding of the patient was not done. This alert describes actions to reduce risk."


Environment / Equipment
  1. Review specifications for all current INR devices in use. Explicitly check whether or not device will give accurate readings with LMW heparin and what type of blood sample should be used.
Communication
  1. Sandbags were added to the checklist of not MRI-safe".""

"Changing Technology, changing risk – Patient Sandbags in the MRI Environment"