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Publication Type: Patient Safety Advisory
Single or Multiple Incident: Multiple
Date: 12/1/2018 12:00:00 AM

This alert discusses the patient safety incidents which can occur related to the use of magnetic resonance imaging (MRI) procedures. MRI uses a magnetic field and radio waves to produce images. Strict attention to MRI screening to prevent ferromagnetic objects and devices from reaching the MR scanner's magnetic field is important for safe MRI. Significant injury can occur to individuals in the MR scanner suite if a ferromagnetic object or a device with ferromagnetic components is exposed to the magnetic field and radiofrequency energy of the MR scanner. To prevent injuries, MRI screening is done to identify ferromagnetic objects before patients, staff, or equipment enters the MR scanner room. This article addresses the identification and analysis of MRI screening events submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) from 2009 through 2017 and reviews strategies for keeping ferromagnetic objects and devices from reaching the MR scanner's magnetic field. Of the 1,108 MRI screening events, 83 events involved two or more objects and/or devices. Of the MRI screening events with identifiable objects or devices, 64.8% involved internal medical devices and nonmedical objects; the most frequently involved items were pacemakers (32.3%). More than one-third of events involved external objects, carried in by or attached to the patient or healthcare staff. Of the events involving projectiles, 10 of the 51 projectiles struck either a patient or a healthcare provider. Other safety concerns specifically associated with projectiles are the potential for damage to the MR scanner and the need to turn off, or "quench," the magnet in response to the event. Quenching the magnetic involves releasing a cooled gas that can lead to displacement of oxygen in the room if not appropriately ventilated, which can cause loss of consciousness and death for anyone in the MR scanner room. Analysis shows that the number of reported MRI screening events submitted has decreased, possibly as a result of focused attention, education, and informational resources on MRI safety; but the increasing number and variety of internal medical devices, nonmedical objects, and medical equipment makes determination of MR compatibility an ongoing challenge. The increase of the potential risk for ferromagnetic devices entering the MRI suite highlight the need for continued awareness and focus on MRI screening. Risk reduction strategies are provided in the alert.

Additional Details

embolization coil, breast tissue expander, breast tissue clip, key ring, battery, contraceptive diaphragms, MRI Scanner, pacemaker, hearing aid, infusion pump, stent, implantable cardioverter-defibrillator,cardiac valve, dental implant, esophageal implant, penile impalnt, uterine implant, surgical clip, bladder stimulator, bone stimulator, bowel stimulator, nerve stimulator, cerebrospinal fluid (CSF) shunt, wires/leads, loop recorder, internal cardiac monitor, fixator, metal plate, screw, staple, cochlear implant, inferior vena cava (IVC) filter, otologic (ear) tubes/implant, EKG leads/electrodes and pulse oximetry probes, arterial line, central line wire, intraosseous line, endotracheal, feeding tube, urinary catheter, endoscopy capsules, digital pill, wheelchair, gas cylinder, walker, stethoscope, laryngoscope
medication patches, medication cream

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