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Publication Type: Patient Safety Advisory
Single or Multiple Incident: Multiple
Date: 3/1/2007 12:00:00 AM
Two issues have come to light concerning magnetic resonance imaging (MRI) hazards. Patients have experienced second and third degree burns to their skin under electrocardiogram electrodes after MRI. Some patients required plastic surgery. A patient was having an MRI when a metal artifact was noted on the images. The MRI was stopped before the patient sustained any injury. The patient had previously undergone a procedure involving the ingestion of a PillCam™. This alert includes actions to reduce risk.

Additional Details

Device:
EKG electrodes

Environment / Equipment
  1. Do not use electrodes after their expiration date.
  2. Use MRI- compatible electrodes and cables.
Rules / Policies / Procedures
  1. "Search in clothing, sheets and covers, and on the patient for electrodes and cables and remove these devices when they are no longer needed for patient monitoring."
  2. "Include on an MRI screening checklist questions concerning the following: PillCams: date of use, date passed from gastrointestinal system; Electrodes/ cables: whether MRI compatible, methods used to completely affix to skin."
  3. "During the MRI, closely observe the images for unexpected metal objects, and immediately stop the procedure if such objects are noted on the images."
  4. "After the MRI, assess the patient for skin integrity issues at electrode sites."
  5. Do not loop cables; keep a blanket between the patient's skin and cables.
  6. "If a burn/injury occurs: treat according to the prescriber's orders, document the occurrence in the medical record, report to/notify appropriate departments of the occurrence, sequester the equipment involved, according to facility policy, for evaluation"
  7. "Affix electrodes completely to the skin surface by drying the area, removing excess hair, and avoiding air gaps."

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