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Publication Type: Patient Safety Advisory
Single or Multiple Incident: Multiple
Date: 9/1/2006 12:00:00 AM
"A post cardiac catheterization patient with a sandbag placed on the left groin went to Radiology for an MRI. The patient was placed on the table. When the technician began to advance the table, the magnet pulled the sandbag from the patient's groin to the outer housing of the MRI unit. Manufacturer labels may not indicate that a "sandbag" contains metal pellets or whether it is MRI compatible or the "sandbag" may be covered by a towel, blanket, or sheet concealing it from the staff. This alert describes actions to reduce risk."

Additional Details

Device:
sandbag

Environment / Equipment
  1. "Evaluating all "sandbags" to confirm they do not contain metal. Do not use the MRI magnet to do this. Instead, use a powerful hand magnet (>1000G) to test sandbags/ other equipment for ferromagnetic properties."
  2. "If the facility must use ferromagnetic sandbags outside the MRI environment, clearly labelling them as containing iron and not for use in the MRIs area."
  3. Purchasing and using only MRI- compatible sandbags that are labelled as such in the MRI environment.
  4. "Confirming that sandbags are non-ferromagnetic before allowing them into the MRI environment, and assuming that items are MRI incompatible until proven otherwise."
Rules / Policies / Procedures
  1. "For non-ambulatory patients, ensuring that potentially magnet objects are not covered by blankets/sheets/ towels or stored on the transport equipment. Consider transferring patients to MRI- compatible transport equipment once they enter the MRI area."
  2. Assigning trained healthcare workers responsibility for physically evaluating the patient and securing the MRI area.
  3. Maintaining/ posting a list of MRI-incompatible equipment (such as ferromagnetic sandbags).
  4. Revising MRI screening checklists to include evaluating the patient for ferromagnetic sandbags prior to entering the MRI environment and replacing such items with MRI- compatible sandbags.
  5. "Prior to MRI, checking patients' medical records to determine whether a recent procedure/ complication may have required the use of a sandbag (such as cardiac catheterization)."
Training
  1. "Heightening awareness of all healthcare personnel throughout the facility/ transferring facilities of the dangers of ferromagnetic items, such as sandbags, in the MRI environment."
  2. Heightening awareness of MRI staff about the need to check for ferromagnetic sandbags on patients brought from other departments/ facilities.

“Sandbags” May Not Be What You Think