Correspondence

Preventable Deaths and Injuries during Magnetic Resonance Imaging

N Engl J Med 2001; 345:1000-1001September 27, 2001

Article

To the Editor:

In July, a six-year-old child undergoing magnetic resonance imaging (MRI) in New York suffered a skull fracture and intracranial hemorrhage after an oxygen tank that had been brought into the room was pulled into the machine at high speed. He died two days later.1

Undetected or misplaced metal objects have caused numerous injuries during MRI. Twenty-four of 46 MRI facilities responding to a survey in 1999 (52 percent) reported the occurrence of MRI-related accidents.2 Large objects involved in such incidents included an intravenous-drug pole, a toolbox, a sandbag containing metal filings, a vacuum cleaner, mop buckets, a defibrillator, and a wheelchair, among others. Five incidents involving oxygen or nitrous oxide tanks, one of which caused facial fractures, have recently been reported.3

To prevent such incidents, most imaging facilities currently provide safety training to employees and administer patients a standardized questionnaire about implants and other embedded foreign bodies before an MRI examination is performed. Although these efforts prevent many injuries, they are inherently limited. System-wide strategies to decrease the incidence of serious errors are important.4 Safety interventions that work continuously and automatically are generally far more effective than efforts to train large numbers of employees or to enlist the assistance of large numbers of patients.

The use of metal detectors over the doors of MRI examination rooms could have prevented every one of the large metal objects listed above from being brought into the MRI rooms and would have prevented the recent death in New York. Highly sensitive walk-through metal detectors, such as those used in airports, are available commercially for about $2,000 to $5,500 and require minimal maintenance. By comparison, a typical MRI unit costs approximately $1.3 million annually to operate and generates net revenues of $1.8 million during use in more than 3000 patients, resulting in an annual net profit of approximately $500,000.5 The cost of installing a metal detector could thus easily be paid for with operating revenues. Factoring in liability savings would further decrease real costs.

Metal detectors should not replace the screening protocols currently in use, since the detectors may be insufficiently sensitive to detect small implanted metal objects, such as aneurysm clips or cardiac pacemakers. Their installation would, however, be an inexpensive, simple, and potentially life-saving addition to current practice.

Christopher Landrigan, M.D., M.P.H.
Children's Hospital, Boston, MA 02115
landrigan_c@hub.tch.harvard.edu

5 References

1. 1

   Chen DW. Boy, 6, dies of skull injury during M.R.I. New York Times. July 31, 2001:B1, B5.
   

2. 2

   Chaljub G, vanSonnenberg E, Johnson RF Jr. Accidents and incidents in MRI: a questionnaire. AJR Am J Roentgenol 1999;172:Suppl:14-14 abstract.
   

3. 3

   Chaljub G, Kramer LA, Johnson RF III, Johnson RF Jr, Singh H, Crow WN. Projectile cylinder accidents resulting from the presence of ferromagnetic nitrous oxide or oxygen tanks in the MR suite. AJR Am J Roentgenol 2001;177:27-30
   Web of Science | Medline

4. 4

   Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001;285:2114-2120
   CrossRef | Web of Science | Medline

5. 5

   Evens RG, Evens RG Jr. Analysis of economics and use of MR imaging units in the United States in 1990. AJR Am J Roentgenol 1991;157:603-607
   Web of Science | Medline

Citing Articles (10)

Citing Articles

1. 1

   Muhammad B. Rafique, Lisa A. Caplan, Qaiser Khan, Douglas Maposa. (2010) Who can pull it out?. Pediatric Anesthesia 20:10, 966-967
   CrossRef

2. 2

   N. Reed Dunnick. (2009) Ensuring Patient Safety: A Summary of the 2008 Intersociety Conference. Journal of the American College of Radiology 6:4, 230-234
   CrossRef

3. 3

   Marc Dewey, Tania Schink, Charles F. Dewey. (2007) Frequency of referral of patients with safety-related contraindications to magnetic resonance imaging. European Journal of Radiology 63:1, 124-127
   CrossRef

4. 4

   A. Stecco, A. Saponaro, A. Carriero. (2007) Patient safety issues in magnetic resonance imaging: state of the art. La radiologia medica 112:4, 491-508
   CrossRef

5. 5

   Reinette Robbertze, Karen L Posner, Karen B Domino. (2006) Closed claims review of anesthesia for procedures outside the operating room. Current Opinion in Anaesthesiology 19:4, 436-442
   CrossRef

6. 6

   Gary A. Ulaner, Patrick M. Colletti. (2006) An unsuspected MR projectile: A “wooden” chair with metal bracing. Journal of Magnetic Resonance Imaging 23:5, 781-782
   CrossRef

7. 7

   David Alspach, Marc Falleroni. (2005) Monitoring Patients During Procedures Conducted Outside the Operating Room. International Anesthesiology Clinics 42:2, 95-111
   CrossRef

8. 8

   G. P. Conners. (2005) Diagnostic uses of metal detectors: a review. International Journal of Clinical Practice 59:8, 946-949
   CrossRef

9. 9

   Patrick M. Colletti. (2004) Size ?H? oxygen cylinder: Accidental MR projectile at 1.5 Tesla. Journal of Magnetic Resonance Imaging 19:1, 141-143
   CrossRef

10. 10

    Jennifer Kulynych. (2002) Legal and ethical issues in neuroimaging research: human subjects protection, medical privacy, and the public communication of research results. Brain and Cognition 50:3, 345-357
    CrossRef