Preventing Accidentsand Injuries in the

MRI Suitej Joint Commission

Magnetic resonance imaging (MRI) wasapplied to health care in the late 1970s toprovide never-before-seen two- and three-

dimensional views of body tissue and structure. Today,more than 10 million MRI, or MR, scans are done inthe United States each year (Fatal MRI Accident isFirst of Its Kind). While the capabilities of the MRIscanner are well-recognized, its inherent dangers maynot be as well known. The following types of injurycan and have occurred during the MRI scanningprocess:

1. ‘‘Missile effect’’ or ‘‘projectile’’ injury in whichferromagnetic objects (those having magneticproperties) such as ink pens, wheelchairs, andoxygen canisters are pulled into the MRI scannerat rapid velocity.

2. Injury related to dislodged ferromagnetic im-plants such as aneurysm clips, pins in joints,and drug infusion devices.

3. Burns from objects that may heat during theMRI process, such as wires (including lead wiresfor both implants and external devices) and sur-gical staples, or from the patient’s body touchingthe inside walls (the bore) of the MRI scannerduring the scan (ACR Guidance Document).

4. Injury or complication related to equipment ordevice malfunction or failure caused by the mag-netic field. For example, battery-powered devices(laryngoscopes, microinfusion pumps, monitors,etc.) can suddenly fail to operate; some prog-rammable infusion pumps may perform errati-cally (Ensuring Safety); and pacemakers and

Reprinted from Sentinel Event Alert, Issue 38, February 14, 2008.� The Joint Commission, 2008. Reprinted with permission.

J Radiol Nurs 2008;27:74-77

1546-0843/$34.00

Copyright � 2008 by the American Radiological Nurses Association.

doi: 10.1016/j.jradnu.2008.04.002

74 www.radiolo

implantable defibrillators may not behave asprogrammed.

5. Injury or complication due to failure to attend topatient support systems during the MRI. This isespecially true for patient sedation or anesthesiain MRI arenas. For example, oxygen canistersor infusion pumps run out and staff must eitherleave the MRI area to retrieve a replacement ormove the patient to an area where a replacementcan be found.

6. Acoustic injury from the loud knocking noisethat the MRI scanner makes.

7. Adverse events related to the administration ofMRI contrast agents.

8. Adverse events related to cryogen handling, stor-age, or inadvertent release in superconductingMR imaging system sites.

Five MRI-related cases in the Joint Commission’sSentinel Event database resulted in four deaths andaffected four adults and one child. One case was causedby a projectile; three were cardiac events, and one wasa misread MRI scan that resulted in delayed treatment.

In 2005, Jason Launders, MSc, a medical physicistwith the ECRI Institute, conducted an independentanalysis of the FDA’s MAUDE (Manufacturer andUser Facility Device Experience Database) reportingdatabase over a 10-year time span, which revealed389 reports of MRI-related events, including ninedeaths: three related to pacemaker failure; two to insu-lin pump failure; and the remaining four events relatedto implant disturbance, a projectile, and asphyxiationfrom a cryogenic mishap during installation of anMR imaging system. More than 70 percent of the 389reports were burns; 10 percent were projectile-related;another 10 percent were ‘‘other events, including im-plant disturbance; 4 percent were acoustic injuries; 4percent were fire-related; and 2 percent were internalheating-related.

The most common patient injuries in the MRI suiteare burns and the most common objects to undergo

JUNE 2008gynursing.org

Joint Commission Preventing AccidentsJOURNAL OF RADIOLOGY NURSING

significant heating are wires and leads. Other objectsassociated with burns are pulse oximeter sensors andcables, cardiorespiratory monitor cables, safety pins,metal clamps, drug delivery patches (which may con-tain metallic foil), and tattoos (which may containiron oxide pigment). Less common injuries involvepacemakers. The American College of Radiology(ACR Guidance Document) recommends that im-planted cardiac pacemakers and implantable cardi-overter/defibrillators should be considered a relativecontraindication for MRI. Any exception should beconsidered on a case-by-case basis and only if the siteis staffed with individuals with the appropriate radiol-ogy and cardiology knowledge and expertise (ACRGuidance Document).

While only one missile-effect case has been reportedto the Joint Commission, they are more common thanis generally recognized. Many peopledincluding healthcare workersdare unaware that the magnets in theMRI scanner are always ‘‘on’’ and that turning them‘‘off’’ (quenching) is an expensive and potentially dan-gerous undertaking, involving the controlled release ofcryogenic gases that can be deadly if released into a con-tained area. As a result of the magnets, many of theobjects pulled into the MRI scanner are cleaning equip-ment or tools taken into the MRI suite by housekeep-ing staff or maintenance workers.

RISK REDUCTION STRATEGIES

Conventional metal detectors have been used to helpidentify metal objects in and on patients, but they arenot 100 percent accurate and can give false-positivesand false-negatives (Radiographic Imaging CEUSource). Furthermore, metal detectors cannot alert per-sonnel to all objects that are subject to heating, mal-function or failure during an MRI scan (What’s Newin MR Safety). However, the recent availability of fer-romagnetic detectors may help in screening patients forobjects left on their person, according to Dr. EmanuelKanal, chair of the ACR’s Magnetic Resonance SafetyCommittee. A recent study concludes that ferromag-netic detectors have 99 percent sensitivity (Thomas &Kanal, 2005).

A report on projectile cylinder accidents in theAmerican Journal of Radiology (Projectile CylinderAccidents) recommends strategies to prevent missile-effect accidents, including implementing protocols thatallow maintenance and housekeeping personnel to en-ter the MRI suite only after proper safety educationand when no patient is in the suite. A number of pre-ventive measures for hazards in the MRI-environmentare recommended by Dr. Kanal (Emanuel Kanal,2001) and are supported by the ECRI Institute (Hazardreport), including:

VOLUME 27 ISSUE 2 www.radiolog

� Appoint a safety officer who is responsible forimplementing and enforcing safety procedures inthe MRI suite.

� Implement systems to support safe MRI practicesuch as written protocols and checklists and peri-odically review, and assess compliance with yourorganization’s MRI policies, procedures andprotocols.

� In general, do not bring any device or equipmentinto the MRI environment unless it is proven tobe MR Safe or MR Conditional. MR Safe itemspose no known hazard in all MRI environments,and MR Conditional items have been demon-strated to pose no known hazards in a specifiedMRI environment with specified conditions ofuse. (American Society of Testing and Materials)The Safety of ‘‘MR conditional’’ items must beverified with the specific scanner and MR envi-ronment in which they will be used.

JOINT COMMISSION RECOMMENDATIONS

The Joint Commission offers the following recommen-dations and strategies to health care organizations forreducing MRI accidents and injuries:

Ferromagnetic Objects

buffing machineschest tube stands

clipboards (patient charts)gurneyshairpins

hearing aidsidentification badges

insulin pumpskeys

medical gas cylindersmops

nail clippers and nail filesoxygen cylinderspulse oximeters

pacemakerspagers

paper clipspens and pencils

IV polesprosthetic limbs

shrapnelsandbags (with metal filings)

steel shoesstethoscopes

scissorsstaplestools

vacuum cleanerswatches

wheelchairs

75ynursing.org

Preventing Accidents Joint CommissionJOURNAL OF RADIOLOGY NURSING

1. Restrict access to all MRI sites by implementingthe four zone concept as defined in the ACRGuidance Document for Safe MR Practices:2007 (ACR Guidance Document). The fourzone concept provides for progressive restrictionsin access to the MRI scanner:

o Zone I: General publico Zone II: Unscreened MRI patientso Zone III: Screened MRI patients and

personnelo Zone IV: Screened MRI patients under con-

stant direct supervision of trained MRpersonnel

2. Use trained personnel to screen all non-emergentpatients twice, providing two separate opportuni-ties for them to answer questions about any metalobjects they may have on them, any implanted de-vices, drug delivery patches, tattoos, and any elec-trically, magnetically, or mechanically activateddevices they may have. If the patient is uncon-scious or unable to answer questions, questionthe patient’s family member or surrogate decisionmaker. If this person is unsure, use other means todetermine if the patient has implants or other de-vices that could be negatively affected by theMRIscan (e.g., look for scars or deformities, scrutinizethe patient’s history, use plain-film radiography,use ferromagnetic detectors to assist in the screen-ing process, etc.) (ACR Guidance Document;Emanuel Kanal, 2001).

3. Ensure that theMRI technologist has the patient’scomplete and accurate medical history to ensurethat the patient can be safely scanned.All implantsshould be checked against product labeling ormanufacturer literature specific to that implant,or peer-reviewed published data regarding the de-vice or implant in question. Technologists shouldbe provided with ready access to this information.

4. Have a specially trained staff person who isknowledgeable about the MRI environment ac-company any patients, visitors and other staffwho are not familiar with the MRI environmentinside the MRI suite at all times (ACR GuidanceDocument; Emanuel Kanal, 2001).

5. Annually, provide all medical and ancillary staffwho may be expected to accompany patients tothe MRI suite with safety education about theMRI environment and provide all staff andpatients and their families with appropriate ma-terials (e.g., guidelines, brochure, poster) that ex-plain the potential for accidents and adverseevents in the MRI environment.

6. Take precautions to prevent patient burns duringscanning, including:

76 www.radiolog

o Ensure that no items (such as leads) areformed into a loop, since magnetic inductioncan occur and cause burns (RadiographicImaging CEU Source).

o If the patient’s body touches the bore of theMRI scanner, use non-conductive foam pad-ding to insulate the patient’s skin and tissues(ACR Guidance Document).

o Place a cold compress or ice pack on EKGleads, surgical staples, and tattoos that willbe exposed to radiofrequency irradiationduring the MR imaging process (ACR Guid-ance Document).

7. Only use equipment (e.g., fire extinguishers,oxygen tanks, physiologic monitors, and aneu-rysm clips) that has been tested and approvedfor use during MRI scans (ACR GuidanceDocument).

8. Proactively plan for managing critically ill pa-tients who require physiologic monitoring andcontinuous infusion of life sustaining drugs whilein the MRI suite.

9. Provide all MRI patients with hearing protection(i.e., ear plugs).

10. Never attempt to run a cardio-pulmonary arrestcode or resuscitation within the MR magnetroom itself.

ReferencesACR guidance document for safe MR practices. (June 2007).

Available from, AJR, 188, http://www.acr.org/SecondaryMainMenuCategories/quality_safety/MRSafety/safe_mr07.aspx.

American Society of Testing and Materials F 2503-05, StandardPractice for Marking Medical Devices and Other Items forSafety in the Magnetic Resonance Environment.

Emanuel Kanal MD, Magnetic Resonance Safe Practice Guide-lines of the University of Pittsburgh Medical Center, 2001.

Ensuring safety for infants undergoing magnetic resonance imag-ing. Medscape. Available from, http://www.medscape.com/viewarticle/499273.

Fatal MRI accident is first of its kind. Available from, www.webmd.com/content/Article/34/1728_85340.htm.

Hazard report: Patient death illustrates the importance of adheringto safety precautions in magnetic resonance environments.(August 2001). Health Devices, 30(8) ECRI.

Projectile Cylinder Accidents Resulting from the Presence ofFerromagnetic Nitrous Oxide or Oxygen Tanks in the MRSuite. (July 2001). AJR, 177.

Radiographic imaging CEU source, LLC, Part 6, MRI SafetyFor Health Care Personnel.

Thomas, S. & Kanal, E. ‘‘Ferromagnetic Detector to ScreenPatients for Metallic Foreign Bodies Prior to MR Imaging,’’Abstract presented at theAmerican Society ofNeuroradiologyannual meeting in Toronto, May 2005. Available from, http://www.koppdevelopment.com/articels/abstract.htm.

What’s new in MR safety. (October 2005). Health Devices, 34(10)ECRI. Includes a ‘‘Starter List of Devices and Equipment forUse in the MR Environment’’.

JUNE 2008ynursing.org

Joint Commission Preventing AccidentsJOURNAL OF RADIOLOGY NURSING

Further ReadingsBurns in MRI patients wearing transdermal patches. (April 8,

2004). Available from, ISMPMedication Safety Alert!�www.ismp.org/Newsletters/acutecare/articles/20040408.asp?ptrZy.

Burns in MRI patients wearing transdermal patches. Video webcast. FDA Patient Safety News, U.S. Food and Drug Adminis-tration, Show #29, July 2004, Available from www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/transcript.cfm?showZ29.

VOLUME 27 ISSUE 2 www.radiolog

Evaluating MRI safety for specific populations: Preparing forpediatric, geriatric, and acute patients. (June 2007). The JointCommission Perspectives on Patient Safety, 7(6)

VA National Centers for patient safety MR hazard summary andMR hazard summarydAugust 2001 update. Available from,www.patientsafety.gov/SafetyTopics/mrihazardsummary.html.

Working together to improve MRI safety. (February 2007). TheJoint Commission Perspectives on Patient Safety, 7(2)

77ynursing.org