Patient Safety in MRI room - 6 learnings for all Medical Practitioners

Rise in the number of MRI scanners has led to a rise in accidents involving it. Regardless of fact whether you own a MRI system or not, but as Healthcare professional you should be aware of essential Patient Safety points related to it.  Six  Learnings  from top Medical errors that have happened in MRI room

1- Projectile Accidents

MRI scanner room where the magnet is kept is an area of high magnetic strength, capable of pulling metallic objects, specially iron. These magnets are not energized  during  scanning , but are in an always on state. The magnetic force of a 10-tom magnet is 30,000 times more powerful than the earths magnetic field.

Few cases  related to accidents in MRI room are :-

- UP Minister Satyadev Pachauri's  security  officer's  gun  pulled by Magnet

- Woman seriously injured by metallic stretcher brought to shift her.

- GE pays Rs 1 crore to technician who got stuck to MRI room

Learnings for you: 

1. No access to outsiders, only authorized personnel should be allowed.
2. The Magnet room entrance should be in two layers.
3. No magnetic object should be in Vicinity of Magnet room.
4. Oxygen Tanks, Mobile, Scissor, Cigarette, Clipboards, Watch & Metallic Stretchers etc. should not be allowed .

2- Non Declaration of Implants and Metal wearables

MRI staff  through a Questionnaire should make sure about any implant / Metal device inside patient’s body. Patient with any of the following devices should be prohibited:

• Vascular implants (e.g. stents, clips, coils, valves)
• Orthopaedic implants and devices (e.g. hip prostheses, nails, wires, fixation systems)
• Active Implants (e.g. pacemakers, neurostimulators, infusion pumps, pressure sensors)
• Surgical / Interventional instruments (e.g. scissors, guidewires, manipulators)
• Medical electrical devices (e.g. pulse oximeters, anaesthesia and monitoring equipment, injectors, ventilators, robotic systems)
• All ancillary equipment used within the MR environment.

Case – Pacemaker death after error in hospital

Learnings for you:

Only implants identified by the manufacturer as MRI safe or MRI conditional are safe to scan.

3- Burns from ECG Leads

MRIs use RF transmitters and those can cause heat. Clinicians are aware of absolute contraindications for MRI, but may not be familiar with other hazards of these devices, including burns.

Here are two unusual cases of burns from ECG leads, sus-tained within MRI scanners, and discuss possible mechanisms of energy transfer within this environment that may give rise to burn injuries.

Case 1– A 59-year-old female, underwent a 120-minute MRI scan on a  1.5 Tesla machine . The scan proceeded with full anaesthetic monitoring and MRI-compatible ECG cable and monitor  . Upon recovery, the patient immediately complained of burning abdominal pain. A red blistering line was noted from the xyphoid to the peri-umbilical area, in the position of the patients ECG cable.

Case 2– A 44-year-old male patient, chronic back pain underwent a 60 minute spinal MRI scan. Due to claustrophobia, the scan was performed under general anaesthesia , using similar scanner type and monitoring devices as described above. Before scanning, a 2.5cm thick cotton wool strip was placed between the patient and ECG cable. Examination revealed an erythematous, blistered line, 8cm in length, on the anterior abdomen , corresponding to the position of the ECG cable during the scan.

4- Tattoo  Induced Skin Burn during MRI scan

Ink of a Tattoo may contain particles of iron that, by interacting with the magnetic field, can cause sensations of heat, burns, swelling or local irritation during an MRI examination.

Case – Tattoo-Induced Skin  Burn during Magnetic Resonance Imaging in a Professional Football Player

Learning for you:

Put in MRI questionnaires that gets filled by patient, if he / she has any tattoos or not.