MRI related injuries are increasing

The Joint Commission has just issued Sentinel Event Alert #38 on MRI accidents. http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_38.htm
            Based on the FDA’s accident reporting database (believed to represent significantly less than 10% of events), accidents in the MRI suite have experienced a dramatic increase. This increase is believed to reflect a number of combined risk factors including (1) greater attractive forces from newer magnet systems, (2) higher patient acuity levels, (3) increasing interventional applications and (4) growing numbers of sedation / anesthesia patients.
            The current Sentinel Event Alert identifies risks associated with several issues, including heating, implants that are contraindicated in the MR environment, and projectile / missile events.

Heating:
            Heating incidents can arise from improper positioning of the patient during the exam or incorrect settings on the MRI for a particular scan. Corrective actions can include providing insulation between the patient and the MRI, proper body positioning, and review of scan parameters.
Implants:
            A number of implants, both active devices such as pacemakers and passive implants such as aneurysm clips, can present significant dangers to patients when exposed to either static (unchanging) or time-varying magnetic fields. Other implants, such as the leads used in cardiac devices or nerve stimulators, can experience significant local heating as a product of the normal radiofrequency (RF) energies used during the MRI examination process. Corrective actions to prevent scanning of patients with contraindicated implants include a careful review of the patient’s medical record, patient interviews, education of referring physicians, and scrutiny of all identified surgical procedures. (For up-to-date information on the safety of implants, please visit http://www.MRIsafety.com or http://www.doctordoctor.biz )
Projectiles:
            Despite the near-universal awareness of MRI magnets’ extreme power of attraction, objects containing steel are regularly brought into MRI rooms where they are ‘sucked’ into the MRI scanner. Often, these objects are small enough to be removed by hand, but larger objects often require very expensive service calls to have them removed from the scanner. Small objects such as bobby pins and nail clippers, however, can – and do – cause injuries when drawn into MRI magnets, striking patients and/or staff. Corrective actions to prevent projectile accidents include increased vigilance in screening patients and objects, as well as the gowning of all patients. One specific recommendation of the Sentinel Event Alert is for the use of contemporary ferromagnetic detection (FMD) systems specifically designed to find projectile threats in the MRI suite. (For links to all three manufacturers of FMD systems, see http://www.MRI-Planning.com/vendor_links.html ) (from the NPSF patient safety foundation list server).