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Cases & Commentaries
- Web M&M
John Gosbee, MD, MS; Laura Lin Gosbee, MASc; February 2003
An infusion pump being used for routine sedation in a child undergoing a magnetic resonance imaging (MRI) scan flew across the room and hit the MRI magnet, narrowly missing the child.
FDA public health notification: MRI-caused injuries in patients with implanted neurological stimulators.
Schultz DG. Rockville, MD: Center for Devices and Radiological Health, Food and Drug Administration; May 10, 2005.
In response to reports of injuries in patients with implanted neurological stimulators who underwent magnetic resonance imaging procedures, the Food and Drug Administration suggests related precautions for radiology personnel and physicians.
Rozovsky FA, Gilk TB, Latino RJ. Mater Manag Health Care. 2006;15:18-23.
This article discusses risk management in magnetic resonance imaging facilities and the use of root cause analysis to inform risk management methodologies.
Patient Safety Initiative Alert. Trenton: New Jersey Department of Health and Senior Services; May 2006.
This announcement describes a near miss involving sandbags filled with metal shot instead of sand.
Journal Article > Commentary
Gilk T. Patient Saf Qual Healthc. September/October 2006;3:16-18, 20-21.
The author discusses safety risks in the MRI suite and how suite design can mitigate these risks.
Gilk T, Latino RJ. Patient Saf Qual Healthc. November/December 2011;8:22-23,26-29.
Describing a case of accidental patient death in an MRI suite, this article reviews a root cause analysis of the event and notes that no regulatory efforts have been implemented to improve MRI safety in the 10 years following the incident.
Journal Article > Study
Mansouri M, Aran S, Harvey HB, Shaqdan KW, Abujudeh HH. J Magn Reson Imaging. 2016;43:998-1007.
This analysis of incident reports related to magnetic resonance imaging found that, similar to other settings, incident reports are infrequent, and most do not result in patient harm. Common reasons for reports were associated with test orders, adverse drug reactions, and safety of intravenous medication administration. Given known under-reporting in voluntary reporting systems, future work should incorporate other safety hazard detection methods.