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Publication Type: Medical Safety Information
Single or Multiple Incident: Multiple
Date: 9/1/2007 12:00:00 AM
Country: Japan
This alert describes two patient safety incidents, one causing patient harm, as a result of metal products, which are magnetic, being taken into the MRI room and not removed once the MRI has commenced. In one case a patient on oxygen was taken into the MRI room on a gurney from the emergency room. A clinical radiologist thought the gurney and the oxygen tank were for exclusive use in the MRI room and did not check their identification. When the gurney was moved close to the MRI device in order to move the patient to the platform, the oxygen tank flew out and stuck to the MRI gantry. In the other case, a nurse prepared a sedative for a child undergoing MRI and put the sedative into an enamel tray and left it in the anteroom adjacent to the MRI room. The clinical radiologist took the tray from the anteroom into the MRI room, put it on the platform near the child's feet, and started the sedation procedure. When the child was asleep, the platform was moved to the head of the MRI device to start scanning. The enameled tray placed close to the child's feet was pulled towards the MRI gantry, the used articles in the tray flew out and some of the articles hit the child which caused a laceration in the child's mouth.

Additional Details

Device:
MRI

Environment / Equipment
  1. Ensure a thorough checking system to prevent magnetic materials (e.g. metal products) from entering the MRI room.
  2. Ensure a thorough checking system to prevent magnetic materials (e.g. metal products) from entering the MRI room.

Magnetic material (e.g metal products) taken in the MRI room