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Publication Type: Patient Safety Advisory
Single or Multiple Incident: Multiple
Date: 6/1/2009 12:00:00 AM
"Magnetic Resonance Imaging Scanners exert magnetic pull on unrestrained objects, causing them to be airborne, and drawn into the scanner's magnet bore. This phenomenon is known as the projectile effect and can result in catastrophic consequences for individuals near the scanner and cause significant damage to the equipment. Additionally, the static magnetic field may cause medical equipment to malfunction, which may result in serious or fatal patient safety incidents. MR personnel must know what equipment is safe to allow into the scanner room and what equipment is unsafe and should be left out of the room. Proper MR screening practices for ferromagnetic items and establishing protocols for identifying and labelling equipment that can and cannot be brought into the scanner room will help reduce the risk of objects becoming projectiles. In one patient safety incident, a police officer was scheduled to undergo an MRI examination. Upon entering the room, he misunderstood the technologist and brought his firearm into the scanner room. The force of the magnet pulled the fun from the officer's hand and drew the gun to the magnet bore, which spontaneously discharged a bullet that struck a wall. No injuries occurred as a result of this potentially serious safety incident. This Patient Safety Advisory provides actions to reduce risk when performing MR examinations. "


Environment / Equipment
  1. "Maintain a list of MR SAFE, MR CONDITIONAL (including conditions for safe use), and MR UNSAFE equipment in every MR department or facility. When possible, identify the safety conditions directly on an object or device. If MRI systems are upgraded or newly"
  2. "Consider the use of ferromagnetic-only detection systems as an adjunct to your facility’s MR safety practices (based on the findings of the University of Pittsburgh Medical Center study, and recommendations from ACR, VA, and the Joint Commission)."
  3. Do not alter MR SAFE or MR CONDITIONAL equipment. Altering equipment may negate the MR safety characteristics of the equipment.
  4. "All equipment brought into the MR environment should be properly labelled (e.g., MR SAFE, MR CONDITIONAL) and should be physically secured at a safe distance (defined by the equipment supplier) from the MRI system using nonmagnetic means (e.g., nonmagneti"
  5. Prohibit equipment and devices within Zone 4 without first verifying that they have been tested by the device manufacturer or properly trained expert and they have been labelled according to the ASTM device terminology- MR SAFE or MR CONDITIONAL- for the
Rules / Policies / Procedures
  1. "Identify the four MR safety boundaries as defined by ACR in its “ACR Guidance Document for Safe MR Practices.” Mark the boundaries with appropriate signage. Zone 4, the area containing the MRI scanner that is associated with the strongest magnetic field, "
Training
  1. "Provide training on MR safety considerations to all MR staff and other personnel who may need access to the MRI scanner room. Include education on the new MR device terminology, the old MR device terminology, and the difference between two nomenclatures."

Safety in the MR Environment: Ferromagnetic Projectile Objects in the MRI Scanner Room