It’s been 10 years since we discussed the tragic death of a 6-year old boy due to a flying projectile in an MRI suite (see our February 19, 2008 Patient Safety Tip of the Week “MRI Safety”) .
But a recent report (Pappas 2018) of another fatality related to a projectile in an MRI unit reminds us that this danger persists despite all the attention given to safety in the MRI suite. A 32-year old man was visiting a relative, who was a patient at a hospital in Mumbai, India, and was handed a metal oxygen cylinder to carry. They were shifting the patient to another stretcher inside the MRI room (Sood 2018). The MRI apparently was on and the oxygen cylinder was pulled toward the core. The victim was standing between the stretcher and the core and was hit by the metallic cylinder, which fell and crushed his hand. As several others in the room attempted to free the victim from under the cylinder after the magnet was turned off, the victim’s finger was severed and the oxygen cylinder began to leak. He apparently inhaled a huge amount of liquid oxygen and fell unconscious and died a few hours later in an ICU. He apparently also had a pneumothorax (Forrest 2018). Relatives apparently said there was no staff outside the MRI suite to prevent the oxygen tank from being taken inside, and there were no security guards checking for metallic objects (Forrest 2018). It was thought the cylinder was damaged after hitting the machine (Guardian 2018).
Further details include that the metal detector outside the MRI room was apparently not functioning at the time of the incident (Pandit 2018). Also, a radiology resident was apparently left in charge of the MRI suite because MRI nurses are not available after 4 PM on weekends (Barnagarwala 2018). That resident apparently instructed patient and relatives to remove metallic objects and then went into the console room to check with ICU staff as to why the scan was being performed. While a nurse ordinarily monitors the removal of metallic items that a patient may be wearing, the job at that time was done by a “ward boy” who worked in the MICU ward.
Several people, including the radiology resident and a MICU resident, were arrested after the incident! Obviously, staffing and system safety issues were the major culprits here and there is a pressing need for a thorough root cause analysis (RCA).
The Pappas article also notes an incident in 2014 in which a technician at another hospital in Mumbai spent 4 hours wedged inside an MRI machine after he was pinned between a ward assistant carrying an oxygen cylinder and the scanner. The technician lost blood circulation below the waist and was temporarily paralyzed; he also suffered organ damage and internal bleeding.
The case is a stark reminder that the security and safety features surrounding your MRI unit must not lapse at all and that no one carrying ferrometallic items be allowed into the inner room. We’ve stressed in prior columns that this is particularly important to prevent people responding to an emergency from rushing into the room before the magnet is turned off. You cannot assume that staff from other areas understand they must not enter the room. We’ve also stressed that you should work with your local fire and police departments to make sure they are also aware they cannot go into the room when the magnet is active. But inservices and signage are probably not enough. You need a person to physically bar entrance to the MRI room when the magnet is active.
We hope you’ll revisit many of our MRI safety columns listed below. Fortunately, projectile injuries and fatal incidents have been relatively rare but other untoward events may occur.
Some of our prior columns on patient safety issues related to MRI:
Pappas S. Man Dies in MRI Accident: How Does This Happen? Live Science 2018; January 29, 2018
Forrest W. Indian man carrying oxygen tank dies in MRI suite. AuntMinnnie.com 2018; January 29, 2018
Sood M. Gas leak or chest injuries: What killed 32-year-old man at Mumbai hospital’s MRI room? Hindustan Times 2018; updated January 28, 2018
The Guardian. Man dies after being sucked into MRI scanner at Indian hospital. The Guardian 2018; January 29, 2018
Pandit S. Metal detector in Mumbai hospital’s MRI room was not functional, unit had piped oxygen: BMC. Hindustan Times 2018; Updated: Feb 01, 2018
Barnagarwala T. Doctors should not be punished for MRI death: Radiology body. The Indian Express 2018; February 12, 2018