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Publication Type: Patient Safety Advisory
Single or Multiple Incident: Multiple
Date: 3/1/2009 12:00:00 AM
"Electromagnetic and ferromagnetic materials in close proximity to a magnetic resonance imaging (MRI) scanner can be a hazardous safety risk to any individual near the scanner. To avoid injury from interference and attraction effects, individuals are screened before entering the MRI scan room with interviews a questionnaire (MR screening form). The MR screening form contains questions to ask individuals needing access to the MRI scan room in order to identify potential contraindicated objects on or in their bodies, such as an implanted cardiac pacemaker. The magnetic field of the MRI scanner could negatively affect ferromagnetic objects implanted in an individual as objects would be pulled into the magnetic field which may cause harm to patients and staff. Several patient safety incidents were reported and described events in which the MR clinical screening process was inadequate and, in some cases, erroneously permitted patients with implanted pacemakers and other ferromagnetic objects into the MRI scanner room. Rigorous MR screening practices will help reduce hazards from contraindicated implants and ferromagnetic objects in close proximity to the MRI scanner. Actions to reduce risk have been provided in this Patient Safety Alert."


Communication
  1. Share the Patient Safety Advisory Alert with all staff involved with MR safety.
Rules / Policies / Procedures
  1. "Compare your facility's MR screening form against the sample MR procedure screening form, available from the Pennsylvania Patient Safety Authority Web site at http://www.patientsafetyauthority.org, to identify content that current forms may omit."
  2. Review your facility's MR-related Incident and Serious Event reports to address potential short comings in MR screening processes that could affect the safety of individuals entering the MR environment.
  3. Talk with appropriate staff to identify barriers to effective screening practices.

Safety in the MR Environment: MR Safety Screening Practices