What’s New in the
Patient Safety World
March 2018
MRI Death a
Reminder of Dangers
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:
- 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”
- August 2016 “Guideline
Update for Pediatric Sedation”
- October 2016 “MRI Safety: There’s an App for That!”
- January 17, 2017 “Pediatric
MRI Safety”
- August 8, 2017 “Sedation
for Pediatric MRI Rising”
- March 2018 “MRI
Death a Reminder of Dangers”
- March 2018 “Cardiac
Devices Safe During MRI But Spinners!?”
References:
Pappas S. Man Dies in MRI Accident: How Does This Happen? Live Science 2018; January 29, 2018
https://www.livescience.com/61558-mri-accident-death.html
Forrest W. Indian man carrying oxygen tank dies in MRI suite. AuntMinnnie.com 2018; January 29, 2018
http://www.auntminnie.com/index.aspx?sec=sup&sub=mri&pag=dis&ItemID=119713
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
https://www.theguardian.com/world/2018/jan/30/mri-scanner-india-death
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
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