What the Recent MRI Disaster Teaches Us About the Importance of MRI Safety Education
Magnetic Resonance Imaging is a powerful tool allowing healthcare professionals to peer into the human body without the risks of ionizing radiation like in the case of the scanner or X-ray. However, with this great power comes great risk of misuse. The use of MRI poses significant risks to patients and staff if proper safety precautions are not followed. Therefore, it is essential that hospital staff who work with MRI machines receive basic safety training to prevent accidents and injuries.
About a month ago, at the Redwood City Hospital in California, a hospital bed was pulled into an MRI scanner, damaging the machine while it was turned on. A nurse and nursing assistant brought the patient directly into the scanner room. The MRI tech was not in the vicinity to avoid the disaster. As the hospital bed was drawn to the scanner by the magnet, the patient was thrown off the gurney. Thankfully, they are relatively unharmed. The nurse, however, did suffer injuries as she was pinned between the bed and the scanner. Ultimately, she had to go to surgery for her broken femur and pelvis. The magnet of the MRI had to be quenched, which is not only very expensive due to the escaping helium, but also destroys the coils of the magnet, so the MRI was most likely replaced.
Fig 1: Image of the bed 1
Accidents like these are often pinned on the MRI tech, who was not present as the nurse entered the room.
This unfortunate accident is an example of why MRI safety education is essential for everyone, even nurses that are not involved in the radiology department. In addition, there is a need for more MRI techs who are spread thin and must keep an eye on active machines at all times. A lot of hospital staff are not aware that the magnet is always on because they don’t hear it. MRI’s have a superconductive magnet of 1.5 to 3 Tesla while on.
MRI machines generate a powerful magnetic field that can attract metal objects within its vicinity. Therefore, it is essential that all individuals entering the MRI suite be screened for metallic objects. Metal objects can be pulled towards the machine and become projectiles, causing severe injury or damage. MRI machines also generate radiofrequency (RF) waves that can cause burns and heating of tissue if the power levels are not adequately controlled.
Hospital staff who work with MRI machines, including radiologic technologists, nurses, and physicians, must receive basic safety training to ensure that they understand the risks associated with MRI procedures and how to prevent accidents and injuries. The training should cover the following topics:
- MRI Safety Basics: Staff should receive an overview of MRI technology, including the magnetic field and RF waves generated by the machine. They should also be trained on how to identify and handle potential hazards in the MRI suite
- Screening Procedures: Staff should be trained on how to screen patients and visitors for metal objects before entering the MRI suite. This includes checking for items such as jewelry, watches, and hearing aids, which can be pulled towards the machine by the magnetic field
- Emergency Procedures: In the event of an accident or injury in the MRI suite, staff should know how to respond quickly and appropriately. This includes knowing how to turn off the MRI machine and how to administer first aid
- RF Safety: Staff should receive training on how to control the RF power levels generated by the MRI machine. This includes understanding the importance of proper RF coil placement and monitoring the patient’s temperature during the procedure to prevent burns and tissue damage
- Access Control: Access to the MRI suite should be restricted to authorized personnel only. Staff should be trained on how to control access to the suite and prevent unauthorized individuals from entering the area
The hospital released this statement on March 22, 2023:
Fig 2: Statement released by Kaiser Permanente
Kaiser Permanente is adamant that the disaster was an “isolated occurrence”. According to the hospital’s policy, individuals entering the wing of the hospital where the MRI is located must have MRI safety training. Is this only a written policy that is lenient with its enforcement, or do healthcare professionals working in the hospital willfully disregard the policy? Regardless, the onus is on the hospital to enforce MRI safety education on its employees, because the alternative is too severe to omit it.
An event report was issued by the FDA on March 22 2023 as well. The event description reads: “It was reported that a hospital bed was taken into the scan room when it became attracted to the magnet. A staff member sustained injuries which required medical treatment.” However, it states an investigation is in progress, so we may get more information on this disaster in the coming months.
Both the statement and the report did not include much detail as to the level of safety education the nurse had received, and what specific actions the hospital will take to ensure this never happens again.
MRI basic safety training is essential for hospital staff who work with MRI machines. It is crucial that staff understand the risks associated with MRI procedures and how to prevent accidents and injuries. By providing basic safety training, hospitals can ensure that their staff is knowledgeable and competent in MRI safety procedures, thus providing a safe environment for both patients and staff. With more knowledge, accidents like these can be avoided.
It is also important to remember that this does tend to be the MRI tech’s responsibility, so increasing the number of techs to two per machine is also a safety precaution, not only a way to make the job easier.
To all techs: make sure to lock the door to the scanner before leaving the room!
1 The original image was posted on Reddit on February 26, 2023 to the subreddit r/Radiology [Link]
2 Image posted on Twitter by Tobias Gilk, MRSO, MRSE (@TobiasGilk) [Link]
2 “MAUDE Adverse Event Report: GE MEDICAL SYSTEMS, LLC DISCOVERY MR750 3.0T NUCLEAR MAGNETIC RESONANCE IMAGING.” Accessdata.fda.gov, FDA, 22 March 2023 [Link]
Disclaimer: The information provided on this website is intended to provide useful information to radiologic technologists. This information should not replace information provided by state, federal, or professional regulatory and authoritative bodies in the radiological technology industry. While Medical Professionals strives to always provide up-to-date and accurate information, laws, regulations, statutes, rules, and requirements may vary from one state to another and may change. Use of this information is entirely voluntary, and users should always refer to official regulatory bodies before acting on information. Users assume the entire risk as to the results of using the information provided, and in no event shall Medical Professionals be held liable for any direct, consequential, incidental or indirect damages suffered in the course of using the information provided. Medical Professionals hereby disclaims any responsibility for the consequences of any action(s) taken by any user as a result of using the information provided. Users hereby agree not to take action against, or seek to hold, or hold liable, Medical Professionals for the user’s use of the information provided.