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Publication Type: Risk Alert
Single or Multiple Incident: Multiple
Date: 7/1/2014 12:00:00 AM
Country: Hong Kong

This alert discusses potential patient safety incidents related to Magnetic Resonance Imaging (MRI) and the presence of non-MRI compatible devices. Non-MRI compatible devices are highly dangerous as the ferromagnetic property and electric conductivity of MRI can cause device failure, displacement, burns or death which are preventable. Examples of non-MRI compatible devices include the following: pacemakers, vagus nerve stimulators, cochlear implants, deep brain stimulators, implantable cardioverters, magnetic foreign bodies or metal implants such as aneurysm clips and surgical prostheses. A hospital recently reported some near miss events related to MRI safety. The information of whether the patients had implants / devices / object materials and the MR compatibility was not filled in or clearly stated in the request form. The radiographer detected the errors on site before the MRI scanning. Several patients had their appointments deferred for further clarification of MR compatibility while one had the appointment cancelled due to MR incompatibility. Examples of the incidents reported were: - The spine MRI appointment of an outpatient with an implanted pacemaker had to be cancelled. - There was discrepancy in the information provided in the MRI request and consent forms for a patient with implanted material. - A patient with an electronic programmable ventriculoperitoneal (VP) shunt was booked for MRI investigation. - Metallic implants were not stated in the MRI Request Form. Recommendations to prevent similar patient safety incidents are provided.

Additional Details

Device:
electronic programmable ventriculoperitoneal (VP) shunt, pacemakers, vagus nerve stimulators, cochlear implants, deep brain stimulators, implantable cardioverters, aneurysm clips, surgical prostheses


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