Sign In
CPSI Share                                                                      
​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​ ​​
Back to Search
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."


Environment / Equipment
  1. The Department strongly recommends that all “sandbags” are carefully examined to ascertain that they are indeed filled with sand and that you also check with your vendors to ensure that there are no miscommunications about orders.
Rules / Policies / Procedures
  1. "If you have metal shot filled bags, and there is any possibility that a patient could leave an area with the bag and go for an MRI, or any other procedure where the presence of metal is contraindicated, you should remove all of the metal shot bags at your"

MRIs & Sandbags Filled with Metal Shot