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What’s New in the Patient Safety World

January 2022

MRI Safety Issues



The website is a very valuable site for information on safety in a variety of imaging venues. Over the past several months there have been a number of MRI-related safety events reported on that website.


Perhaps the most bothersome report was another fatal incident involving an oxygen cylinder in an MRI unit (Yee 2021a). Projectile accidents in MRI suites are, of course, the most feared events. The recent event occurred in a South Korean hospital, where a 60-year-old man was killed when an oxygen cylinder was carried into the MRI scanning suite during his exam. The oxygen cylinder was apparently already on the pallet on which the patient was brought into the suite. During the scan, it was shifted about two meters and was sucked into the device, killing the patient.


Yee points out that it has been almost 20 years since 6-year old Michael Colombini was killed when a hospital staff member brought a portable oxygen tank into the MRI room. That tank was sucked into the MRI and struck the child in the head. Colombini's death kicked off what has now been a decades-long effort to prevent these kinds of events. We discussed that incident in our October 25, 2011 Patient Safety Tip of the Week “Renewed Focus on MRI Safety”, including the outstanding root cause analysis done by Tobias Gilk and Robert Latino published in Patient Safety and Quality Healthcare (Gilk 2011). The incident, like almost all other incidents we see with bad patient outcomes, was the result of a cascade of events, not a single error or event. And many (in fact most) of the contributory events were not temporally related to the accident but rather were related to the design, planning, and oversight of the MRI unit.


Tobias Gilk actually discussed both the recent South Korean incident and the Columbini incident in a video at the RSNA 2021 conference (RSNA 2021). He notes that we often put too much of the burden on accident prevention on the MRI technologist rather than changing the structure of MRI safety. He stresses we need more “built-in” preventions to stop such accidents from occurring. He points out the striking lack of regulatory oversight of MRI facilities in the US. He points out that newer technologies, like different strength magnets and point-of-care MRI, raise new safety issues. A big problem in recent years is that the COVID-19 pandemic has led to lesser availability of MRI technicians and that remaining MRI technicians may be less experienced. That is a challenge as the pent-up demand for MRI imaging now stresses the system.


We discussed another death related to an oxygen cylinder acting as a projectile in an MRI suite in our March 2018 What's New in the Patient Safety World column “MRI Death a Reminder of Dangers”. Projectile incidents, in addition to other safety issues, were also discussed in our January 7, 2020 Patient Safety Tip of the Week “Even More Concerns About MRI Safety”. And, though it was not technically a “projectile” incident, our November 5, 2019 Patient Safety Tip of the Week “A Near-Fatal MRI Incident” discussed an incident in Sweden in which a nurse wearing some sort of “weight belt” was sucked up against the MRI unit and rendered unconscious by the strap of that belt wrapping around his neck.


And as many hospitals and other facilities are installing newer MRI scanners, another recent accident raises a different issue. A worker was killed in Utah has an MRI scanner was being moved from the 4th floor of a hospital to the 1st floor (Casey 2021, Yee 2021b). The scanner fell to the ground near the facility's loading dock, killing the worker who apparently fell alongside the scanner. The Yee article also discusses the risk of helium release from such a dropped MRI scanner.



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






Yee KM. Oxygen cylinder kills South Korean man in MRI accident. 2021; October 18, 2021



Gilk T, Latino RJ. MRI Safety 10 Years Later. What can we learn from the accident that killed Michael Colombini? Patient Safety and Quality Healthcare 2011; online first Nov-Dec 2011



Video from RSNA 2021: Tobias Gilk on MRI safety. 2021; November 30, 2021



Casey B. Falling MRI scanner kills worker at Utah hospital. 2021; September 15, 2021



Yee KM. Industrial MRI accidents are uncommon, but can be deadly. 2021; October 13, 2021







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