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MRI Accident Earlier This Year Kills Service Engineer Who Was Sucked in And Pinned to the Unit– FDA Investigation

Posted Jun 15 2010 12:15pm

If you read the content here is appears that a cluttered room with shelves and other items is the potential problem here and what led to the service technician being struck and pinned to the MRI. 

As the writer here points out, the magnets do not go to sleep and thus safety as far as what articles are in the MRI room are important.  If there’s anything metal it image can get sucked in.  We had an incident right here in Orange County at Hoag Hospital a few months ago where the hospital was fined.

Perhaps we will be seeing smaller MRI machines in the future, just recently there was a breakthrough on the ability to produce a smaller magnet too.  BD

Just a few months ago a service engineer was replacing a fan-blower assembly in an MRI unit (a part that is notoriously ferromagnetic). Working alone in the suite in the evening, after the regular staff had left, the engineer had finished early… or that’s what the security guard thought when he called to her and got no reply.

Turns out that she had been struck and pinned to the MR scanner by the blower assembly, and was unconscious, if not already dead, when the guard checked to see if she was still there.

This tragic story is something of a departure from my typical mantra of patient and staff safety. Yes, this was a trained individual who knew about the risks of the MR environment and materials she was working with. And yes, this was a vendor, and not a hospital worker or patient. But this is a repeatable condition, and an accident which, because there have been MRI accidents involving such a tremendous variety of ferromagnetic materials, deserves a little analysis for a ‘lessons-learned’ output.

In this case, the clearances around the magnet were uncomfortably tight, and what space there was between the magnet and the walls of the suite was purportedly infringed by shelves, storage and clutter.

Personal computers, iPods, filing cabinets, desk chairs, anesthesia machines, cribs, gurneys, wheelchairs, dollies, staplers, power tools, axes, roller skates, ’sand’ bags, hampers, mop-buckets, and the list goes on, and on, and on… All of these, and many, many more objects have found their way into MRI scanner rooms. Sometimes the people involved, like in the circumstances surrounding the recent fatality, know that they’re taking a risk. But at least as often the accident occurs because the person is unaware of what they’re doing.

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