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Publication Type: Alert
Single or Multiple Incident: Single
Date: 5/1/2006 12:00:00 AM

"Immediately following a cardiac catheterization, a patient required an emergency MRI. Standard practice in the catheterization lab was to apply pressure to the groin, the site of catheter access, by using a towel-wrapped sandbag before leaving the catheterization lab to assist with clotting at preventing formation of hematomas. When the MRI was initiated, the sandbag moved towards the patient's head and adhered to the side of the machine. The patient suffered no serious injuries in this near miss. Further examination of the sandbag determined that it was actually filled with metal shot despite all documentation, original order forms, invoices, product number and packing slips stating that it was indeed a "sandbag". The Department provided actions to reduce risk."

MRIs & Sandbags Filled with Metal Shot