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Publication Type: Risk Alert
Single or Multiple Incident: Multiple
Date: 1/1/2008 12:00:00 AM
Country: Hong Kong
"This alert concerns multiple incidents and near misses related to Magnetic Resonance Imaging (MRI). Staff should be aware of patient contra-indications and how to follow proper process when performing an MRI. Patient safety incident examples include a near miss involving a patient with a pacemaker, harmful incidents where patients were injured with magnetic objects becoming projectiles in the MRI field, and the melting of electrodes during a scan. Key actions to reduce risk have been outlined. "


Environment / Equipment
  1. Use MRI compatible ECG electrodes.
Communication
  1. Advise patients to report any discomfort immediately during scanning and closely monitor unconscious patients for early detection of any problem.
  2. Provide patient education on implanted medical devices and other contraindications to MRI scanning through patient information leaflets in outpatient clinics and wards.
Rules / Policies / Procedures
  1. Be aware of and strictly follow the safety guidelines for MRI examination room. Metal objects such as scissors or mobile phones must not be brought into the MRI examination room.
  2. Check routinely by trained nurse from the MRI unit to ensure good contact between ECG electrodes and the patient's skin.
  3. Ensure that the patient's skin is dry before applying ECG electrodes.
  4. Ensure policy and procedures are in place to check for contraindications to MRI and to conduct proper preparation for undergoing MRI examination.
  5. "Be aware that magnet is on all the time, irrespective whether the machine is in use or not."

MRI - Associated Incidents and Near misses