Fatal MRI Accident Brings Safety Measures Back to the Forefront

Leandro Mathias de Novaes would share pro-gun content on social media (Image: Jam Press)

The recent death of a Brazilian man in an MRI suite has brought attention again to the safety measures utilized in MRI suites. The MRI’s strong magnet caused the man’s gun to discharge involuntarily, shooting him in the abdomen. The question has been asked worldwide, “How could an accident like this occur in an MRI suite? How did a gun get into the MRI suite?”

It’s essential to know the facts surrounding this tragic accident. The man who died was not the patient — he brought his mother to the facility for an MRI. The facility followed its safety protocol, screening both the mother and her son about the presence of metal; both signed documents stating that they understood the risks of metal being within reach of the strong magnet.

A Health Imaging writer spoke to Tobias Gilk, senior vice president of RAD-Planning and founder of Gilk Radiology Consultants, to assess MRI safety procedures to help prevent future mishaps. He believes that despite considerable advances in patient safety, safety risks are more significant now than in the past. One of the primary reasons for his concern is the proliferation of implanted medical devices.

In the past, patients with implanted devices, including pacemakers, aneurysm clips, certain artificial joints, and pumps, were rare in MRI suites. These patients needed approval from their physicians because their devices could malfunction, causing physical injury or even death.

MRI Safety Risks Increasing

Recently, however, there are now exceptions to the rules — new technology and medical advancements have created many exceptions to the “no implants or metallic foreign bodies inside the suite” rule. Some newer devices are now considered MRI-safe because of no adverse events during clinical trials. These exceptions create a much more complex operating environment — necessitating radiology technicians, providers, and patients to be extra cautious when researching MRI compatibility for make, model, and the serial number of their devices.

• Patients may forget that old aneurysm clip but remember to tell the MRI tech about their recent knee replacement surgery.
• Metal objects may become projectiles if taken in the exam room. Wheelchairs, stretchers, and oxygen tanks are regulated as to their use in the exam room. Examples include a steel oxygen tank that hurled through a cinder block wall from the power of the MRI’s magnet.
• Some clothing contains metallic threads, which can heat up during the MRI exam and burn the patient.
• Cosmetic products, including false eyelashes, hair extensions, and tattooed makeup, can pose risks, as can permanent jewelry and body piercings.

Burns are the #1 cause of injuries in the MRI suite — in fact, amounting to 59% of MRI injuries between 2008 and 2017.

Ways to Enhance Safety in the MRI Suite

Simply saying “no metal in the MRI suite” is not enough to ensure consistency across every MRI screening location across the United States. Policies vary from facility to facility without consistency among all facilities. Gilk thinks the lack of consistency is because there are no minimum safety standards across the US.

Until there are minimum safety standards, each facility can help ensure safety in the MRI suite, beginning with these suggestions:

• Training and qualifications vary from state-to-state. Ensure that your new hires have a minimum of MRI-specific training — many states don’t require RT(MR) credentials to conduct MRI exams.
• Study the best practice guidelines on MRI safety from the American College of Radiology to craft a safety policy.
• The 2015 Revised Requirements for Diagnostic Imaging Services issued by The Joint Commission lists minimum requirements for access to the scanner room, safety risks for patients, and requires safe zones for patients with signage for restricted areas and that warn of the risks of powerful magnetic fields.

Until there are a best practices recommendation linked to accreditation, “Safety First” policies must remain top-of-mind for those in the MRI suite.