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In the wake of the accidental death of a young boy during a routine MRI scan this summer, the nonprofit research agency ECRI of Plymouth Meeting, PA, has issued a hazard report and recommendations for MRI safety. The incident at Westchester Medical Center, a Valhalla, NY, hospital, involved a metal oxygen cylinder that was drawn by the MRI device’s magnetic force into the center of the machine, killing a 6-year-old boy.
"There are a small number of instances of magnetic objects flying into MRI chambers each year," notes Jim Keller, director of the health devices group at ECRI. "We don’t have a real good sense of how many actually occur, because they are not really reported effectively."
Objects drawn into MRIs have included IV poles, parts of a forklift, a helium cylinder, a mop bucket, a laundry cart, a chair, a ladder, a patient lift, a light fixture, a floor buffer, tools, scissors, and traction weights, according to ECRI. However, the incident at Westchester Medical Center is the first death that ECRI is aware of directly caused by an object being drawn into an MRI. These accidents result from a combination of the busy environment and staff carelessness, says Keller, adding that the most important recommendation is to make sure that someone is responsible for safety. "There needs to be someone who is checking on a regular basis and can establish policies and procedures to make sure that devices with magnetic components cannot get into the MRI room."
Among its 14 recommendations, ECRI advises that all personnel who enter the MRI room receive formal safety training and that they always assume that a magnetic field is present.