Patient Safety Tip of the Week Archive

Patient Safety Tip of the Week

October 24, 2023

Serious MRI Accident at Unregulated MRI Center

A serious MRI accident went largely under the radar for over a year because of lack of regulatory oversight of an imaging unit. A prisoner in Arizona was to have an MRI scan (Kovaleski 2023a, Kovaleski 2023b). The prisoner’s guard removed metal shackles from the prisoner’s legs but asked what to do about the metal shackles around her waist. The MRI technician told him not to remove those. As the prisoner walked near the machine, about 3-4 feet away, she was lifted off her feet into the bore of the MRI. She immediately felt “excruciating pain from the belly shackles, which were pulling her harder and harder, and described feeling like she was being ripped in half”.

To make things worse, the tech then asked the prison guard to go in and help and he was also “stuck to the MRI machine because of his gun.”

Several minutes apparently went by before anyone hit the emergency shutoff button, despite pleas from the prisoner and the guard. Apparently, employees were waiting for the lead engineer who had advised them to wait until he got on scene.

The prisoner was taken to the emergency room and the prison took photos of her injuries, which showed a deep cut on her hand that required stitches, bruises, and imprints from where the metal shackles pulled on her body.

The Arizona Department of Health Services regulates and licenses imaging centers but, ironically, this MRI facility had no license found on the health department’s website. Though the company that operates this facility operates more than 60 imaging centers across the state, this company was not regulated by ADHS because of an exemption the state granted the company. Apparently, it had a private provider exemption because it was physician-owned (private providers are only exempt from licensing in Arizona if they are owned by a doctor or doctors who are treating patients at the clinic).

So, the state did not know of the incident for some time. Moreover, the FDA was not notified because the injury did not meet the threshold for reporting. The FDA only requires reporting for what it calls “a serious adverse event” if there was an “admission to the hospital.” This patient was only taken to the ER and never admitted to the hospital. Apparently, the company did voluntarily report this incident to the FDA, but the report was filed more than 10 months after the incident happened. Note also that report which was filed with FDA’s MAUDE Adverse Event Report system says “officer that was with the patient/inmate was not cleared but entered the room to help and was pulled to the MRI machine and stuck to the MRI machine as well. The MRI machine had to be turned off (quenched) to relieve both the patient and the officer from the MRI machine.” The company did not provide the media reporters a reason for the delay in reporting the accident.

The Arizona Department of Health Services is reviewing how it licenses and regulates all imaging centers.

But there is another very important lesson here – we always recommend you do at least an annual inservice on MRI safety with your local police and fire departments (plus include upfront training for new recruits to those agencies). See our October 21, 2014 Patient Safety Tip of the Week “The Fire Department and Your Hospital”. And obviously, if you do business with prison systems you need to include them in those inservices. Perhaps if the MRI center in this incident had done such inservices, the guard might have challenged the MRI tech regarding the shackles and would have known enough to never enter the MRI unit with his gun.

This case is a stark reminder that failure to follow strict MRI protocols has the potential to cause serious injury or death. Two people stuck in the bore of an MRI could lead to asphyxiation of one or both individuals. And what might have happened if the gun discharged!

Some of our prior columns on patient safety issues related to MRI:

· February 19, 2008 “MRI Safety”

· March 17, 2009 “More on MRI Safety”

· October 2008 “Preventing Infection in MRI”

· March 2009 “Risk of Burns during MRI Scans from Transdermal Drug Patches”

· January 25, 2011 “Procedural Sedation in Children”

· February 1, 2011 “MRI Safety Audit”

· October 25, 2011 “Renewed Focus on MRI Safety”

· August 2012 “Newest MRI Hazard: Ingested Magnets”

· October 22, 2013 “How Safe Is Your Radiology Suite?”

· October 21, 2014 “The Fire Department and Your Hospital”

· August 25, 2015 “Checklist for Intrahospital Transport”