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. 2022 Jun 28;7(1):96-102.
doi: 10.22603/ssrr.2022-0110. eCollection 2023 Jan 27.

Medical Accidents Related to Ferromagnetic Objects Brought into the MRI Room: Analysis of the National Multicenter Database by Orthopedic Surgeons

Kayo Inaguma  1 , Toshiaki Kotani  1 , Shunji Kishida  1 , Tsuyoshi Sakuma  1 , Keisuke Ueno  1 , Yasushi Iijima  1 , Daisuke Kajiwara  1 , Kohei Okuyama  1 , Kotaro Sakashita  2 , Shun Okuwaki  1 , Shiho Nakano  3 , Noritaka Suzuki  1 , Shun Nokariya  1 , Ryo Umeda  1 , Tsutomu Akazawa  4 , Kazuhide Inage  5 , Yasuhiro Shiga  5 , Shohei Minami  1 , Yasuchika Aoki  6 , Seiji Ohtori  5
Affiliations

Medical Accidents Related to Ferromagnetic Objects Brought into the MRI Room: Analysis of the National Multicenter Database by Orthopedic Surgeons

Kayo Inaguma et al. Spine Surg Relat Res. .

Abstract

Introduction: Magnetic resonance imaging (MRI) is widely used in orthopedics, but orthopedic surgeons, including spine surgeons, do not have detailed knowledge of MRI-related accidents. We, as orthopedic surgeons, investigated the details of medical accidents related to ferromagnetic objects brought into the MRI room using a national multicenter database.

Methods: We conducted an exploratory analysis of accidents involving MRI ferromagnets based on the Japanese database of adverse medical occurrences. From a total of 104,659 accident reports over nine years, 172 involving the presence of ferromagnetic objects in the MRI room were extracted and analyzed.

Results: The accident reports frequently involved children and the elderly. Nurses filed the highest number of reports (44.8%) by occupation, which was more than twice as many as physicians (19.8%). The most common ferromagnetic devices brought into the MRI rooms were pacemakers (n = 22). There were also large magnetic objects such as oxygen cylinders (n = 12) and IV stands (n = 7). In the field of orthopedics, ankle weights (n = 4), pedometers (n = 3), and artificial limbs (n = 2) were brought in. "Failure to check" was the most common cause of accidents (69%). Actual harm to patients occurred in 9% of cases, with no fatalities.

Conclusions: Manuals and checklists should be developed and continuous education provided to prevent accidents involving magnetic objects brought into the MR scanner room. As orthopedic surgeons, including spine surgeons, we should be cautious with emergency, geriatric, and pediatric patients because their information and medical history may not be accurate. We should not overlook equipment commonly found in orthopedic practice such as ankle weights and pedometers.

Keywords: MRI; ferromagnetic objects; patient safety; reporting system.

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Conflict of interest statement

Conflicts of Interest: The authors declare that there are no relevant conflicts of interest.

Figures

Figure 1.
Figure 1.
Our accident case. On a holiday, a cleaning staff brought a stepladder into the MRI room for an air conditioning inspection. The stepladder was pulled into the MRI gantry, causing no damage to personnel.
Figure 2.
Figure 2.
Flow diagram showing the case selection protocol.
Figure 3.
Figure 3.
Occupation of the staff involved. Nurses were the most common, followed by radiologists and doctors.
Figure 4.
Figure 4.
Ferromagnetic materials brought or about to be brought into the MRI room (n≥2).
Figure 5.
Figure 5.
Classification of accident causes. “Failure to check” was the most common cause, accounting for 69% of all causes.
Figure 6.
Figure 6.
Severity of accidents A: All cases, B: Doctors’ cases, C: Non-doctors’ cases.
See this image and copyright information in PMC

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