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Harrisburg, PA 17120


Phone: 717-346-0469
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MRI Hidden Risks
PA PSRS Patient Saf Advis 2004 Mar;1(1):3. 
 
The PA-PSRS database includes incidents in which an MRI was ordered for a patient who had a cardiac pacemaker.  Fortunately, the procedures were cancelled in both cases. Patient injury might have resulted if these patients had received MRI’s.

The healthcare community is most likely aware of MRI-associated patient injuries/death involving ferrous gas cylinders as projectiles.1,2 Also nationwide, other ferromagnetic objects have been involved in projectile incidents when near MRI’s, such as tools, scissors, IV poles, mop buckets, floor buffers, laundry carts.3

What may be less known are the risks associated with items implanted or imbedded within the patient. Studies of implants and prostheses have been conducted associated with MRI’s.  Some implants can be adversely affected by the MRI’s electromagnetic fields: for example, cochlear implants, internal or external cardiac pacemakers, implantable infusion pumps, cerebral aneurysm clips. Devices that contain a magnet that might move or become demagnetized, such as dental implants or prostheses with magnetic components may also be adversely affected by the MRI. In addition, metal fragments or shrapnel might be twisted or dis-lodged during the procedure, resulting in patient injury. Persons with tattoos may experience skin irritation as a result of an MRI.4.5.6

Many resources are available that can be utilized to develop strategies to reduce the risk of injury or death related to implanted/imbedded objects and the MRI procedure. Such re-sources include, but are not limited, to the following.

  • American College of Radiology  http://www.acr.org
  • Shellock F, Sawyer-Glover A.  The magnetic resonance environment and implants, devices and materials. In: Shellock F, editor. Magnetic resonance procedures: health effects and safety. Boca Raton, FL: CRC Press; 2001
  • ECRI.  Safety concerns in the MR Environment. Healthcare Risk Control. Volume 4 Radiology 5; September 2002
  • Institute of Magnetic Resonance Safety, Education, and Research http://mrisafety.com
  • Gosbee J, DeRosier J. MR hazard summary: August 2001 update. In: VA National Center for Patient Safety; 2001

Notes

  1. Archibold RC. Hospital details failures leading to MRI fatality. The New York Times 2001 August 22; B1 
  2. Patient death illustrates the importance of adhering to safety precautions in magnetic resonance environments. ECRI. 2001 http://www.ecri.org.
  3. Carr MW and Grey, ML. Magnetic resonance imaging. American Journal of Nursing. December 2002: 29.
  4. Shellock FG, editor. Pocket Guide to MR procedures and metallic objects: update 2001. Philadelphia: Lippincott Williams & Wilkins; 2001.
  5. Shellock FG, Editor. Reference manual for magnetic resonance safety.  2002 ed. Salt Lake City (UT): Amirsys; 2001.
  6. Kreidstein ML, et al. Mri interaction with tattoo pigments: case report, pathophysiology, and management. Plastic Reconstructive Surgery 1997; 99(6): 1717-20. 
 
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THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS  
PSA LOGO The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s Web site at www.patientsafetyauthority.org .      
ECRI LOGO ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology.      

ISMP Logo The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.      
 
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